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SAN JOAQUIN LOCAL HEALTH D11hZRICT <br /> FOBS OFFICE USE: 1601 E. Hazelton Ave. , Sedcktdff, Calif. <br /> 1124 Telephone: (209) 466-6781 <br /> AP%ICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �7,7 <br /> (Complete In Triplicate) <br /> Application is hereby made 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 Joaquin' <br /> County Ordinance No. 1862 and the Rules d Regulations af the San Joaquin Local Health District. <br /> JOB ADDRESS/LO ATIy A27 � �� <br /> CENSUS TRACT <br /> Owner's Nana: ti 1 �a. h ori <br /> Phone - P3r , �� '7 <br /> Address - �'G ifs` q} City <br /> Contractor's Name b'�4 5 <br /> License Phone ,} <br /> TYPE OF WORK (Check): NEW WELL �7 DEEPEN -/7 RECONDITION / DESTRUCTION 17 <br /> PUMP INSTALLATION/ / PUMP REPAIR -/-7—pump REPLACEMENT f7 <br /> Other /% <br /> DISTANCE TO NEAREST: SEPTIC TANK go' SEWER LINES PIT PRIVY <br /> LRACII SaM 12 y SEWAGE DISPOSAL FIELD 74 CESSPOOL/SEEPAGE FIT l OTHER <br /> PROPERTY LINE •- PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELLp <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS r�1 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled -- - _ Dia. of- Well Caaitig " 1411 <br /> Domestie/publkc Driven Gauge of Casing . <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection �_ Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump N.P. <br /> PUMP REPLACEMENT: /—/ State Work Done <br /> PUMP ,.REPAIR: /7 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California 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 A FINAL INSPECTION. <br /> SIGNEDt <br /> TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE T <br /> FOR DEPARTMENT USE ONLY <br /> -- <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: 4111, X17 <br /> PHASE II GROUT INSPECTION PHAS III AL INSPECT! <br /> INSPECTION BY DATE INSPECTION BY/V IryDATE <br /> E H 1426 Rev. 1-74 <br />