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SAN JOAQUIN LOCAL h RICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stock. in, Calif. 7 7-�� <br /> . Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 7-6glc"'l <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 /> CounXy Ordinance No 186,2 and the Rules and Regulations of the San Joaquin Local Health District. <br /> AB ADIMESS/LOCATION CENSUS TRACT <br /> Owner's Name-p:� Acr, Phone <br /> AddressC%AC3_ r-aC�� � - ZrJ�ff' 1 City -- � -r ' ��• <br /> Contractor's Name License #2 <br /> 5CL_ _bPhone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN / / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION/� PUMP REPAIR/ / PUMP REPLACEMENT /� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ��"- SEWER LINES} PIT PRIVY V <br /> SEWAGE DISPOSAL FIELD .4 CESSPOOL/SEEPAGE PIT fNy.\\— OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation . L I'J.'�� <br /> VDomestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing ,02_ <br /> Irrigationravel Pack Depth of Grout Seal gyp' <br /> Cathodic Protection V Rotary- Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor r <br /> Type of Pump H.r���\ H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DES-TRUCTION 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 /> info tion is true to t e best -knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR ROUTING AND A FIN E 0 <br /> SIGNED ` TITLE �-- <br /> PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> P SE I <br /> APPLI CCEPTED BY DATE 1-1 <br /> ADDITIONAL COMMENTS: <br /> P I -GR T INSPECTIO PHASE III/FINAL INSPECTION <br /> INSPECTION BY jL DATE INSPECTION BY DATE -7 <br /> E H 1426 Rev. 1-74 3/76 2M <br />