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"J SAN JOAQUIN LOCZA4 _IUCIT <br /> FOR:OFFICE USE: 1601 E. Hazelton Ave. , Stocrton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,S-Sla Y10 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <br /> 3 (Complete In. Triplicate) <br /> Application is hereby niade to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquir <br /> County Ordinance No. 1662 and:the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 'f �" ILe�}2d>u CENSUS TRACT <br /> Owner's Name A,In r,/ �« ,� ,� - Phone , <br /> Address �.� Ci <br /> y . . <br /> .. <br /> Contractor's Name t License Phone <br /> ` TYPE OF WORK (Check): NEW WELL /7 DEEPEN -/_7 RECONDITION /_7 DESTRUCTION %'f <br /> PUMP INSTALLATION/ / PUMP REPAIR -/7 PUMP REPLACEMENT /? <br /> -iOther �a <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY {l, <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER c� <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL Q <br /> INTENDED USE TYPE OF.WELL CONSTRUCTION SPECIFICATIONS '� <br /> Industrial Cable Tool Dia. of Well Excavation <br /> ! Domestic/private Drilled Dia. of Well Casing <br /> G Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout:. <br /> DisposalOther Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractors <br /> "Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done { <br /> PUMP '.REPAIR: /7 State Work Done s <br /> PES�'TRUCTION OF WELL: Well Diameter Approximate Depth <br /> �� Des ribs erial and Procedure <br /> I hereby agree to comply with all laws arfd regulations of the San .Jo quip tical Health District <br /> and the State of Calif6rnia pertaining to or regulating well''construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well., I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS. REPORT of the well and notify them before putting.the..well. in .use.... .The above <br /> information is' true to.the-best .of. my.-knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO GROUTING AND FINAL INSPECTION. <br /> SIGNED TITLE <br /> L-14 01 (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 7 <br /> APPLICATION ACCEPTED BY DATE Z�/. ` — , <br /> ADDITIONAL COMMENTS: Aor <br /> PHASE 11 GROUT INSPECTION PRASIg lI FANINSPECTION, <br /> INSPECTION BY DATE INSPECTION BY ATE VR <br /> E H 1426 Rev. 1--74 _ - - 2M . <br />