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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR,OFFICE USE: 1601 E. Hazelton Ave. , .Stocktori '`Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 15..39'!}0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Z- -7s <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 he described. This application- is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations: of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION QJ}701 f-. A n AkA K4'•. CENSUS TRACT <br /> Owner's Name h im JA O ice t co n t Phone <br /> Address - City '65cyZo.,� <br /> Contractor's Name '7'�, „ ,,,. S�„� License # aZ2oio Phone 8,Rg-.2p&.Z <br /> TYPE OF WORK (Check): NEW WELL/- DEEPEN '/-7 RECONDITION /'7 DESTRUCTION /-7 <br /> PUMP INSTALLATION L-7 PUMP REPAIR /-7—PUMP REPLACEMENT <br /> Other 17 p ` <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL 0 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Diab of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public 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 H.P. <br /> PUMP REPLACEMENT: State Work Done Z' I v�"�.tf �cS44 S," <br /> PUMP:REPAIR: /-7 State Work Done <br /> 29S RUCTION 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 WINAL INSPECTION. <br /> SIGNED TITLE <br /> (DW PLOT PLAN ON REVERSE SIDE <br /> jpR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II G 0 INSPE PHASE II FINAL INSPECT ON <br /> INSPECTION BY DATE INSPECTION BY DATE _o -7J� <br /> E H 1426 Rev. 1-74 1-74 2M <br />