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^� �F/ SAN JOAQUIN LOCAL` HEALTH DISTRICT <br /> FOi�W ICE USE: 1601 E. Hazelton Ave , 7 iockton, Calif. <br /> Telephone":. (2.09) 4616-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7zl-- &`_9'17`rcJ <br /> THIS 'PERMIT EXPIRES 11` YEAR"FROM ;DATE ISSUED Data Issued <br /> (Complete In Triplicate)` a <br /> Application is hereby made to the San Joaquin -Local Health` tristrikct, 'for a permit to construct <br /> and/or install the work herein .described. This application ib'uade 'in compliance-,with San Joaquin. <br /> County:,Ordinance No. 1862 -and the :Rules.and "Regu ions of the;San Joaquin Local4 Health District. <br /> dl <br /> JOB ADDRESS/LOCATION <br /> 1� CENSUS TRACT' <br /> k. <br /> VQ <br /> Owner's Name Phone -4449 :afa <br /> Address � I� <br /> Toe, ddl AMA4 City <br /> Contractor's Name qV414 2a4al,6 License # j Phone a4 yo7 <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /kf RECONDITION /_ DESTRUCTION / <br /> PUMP INSTALLATION / -TPUMP .REPAIR / PUMP .REPLAcEMENT /? _ <br /> Other <br /> e <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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS. <br /> Industrial _� Cable Tool Dia. of Well Excavation V <br /> Domestic/private Drilled Dia. of Well Casing I<Ll <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 B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done. <br /> PUMP ,.REPAIR: /7 State Work Done <br /> ZES®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 GROU ING .AND A FINAL INSPECTION. <br /> SIGNED - TITLE <br /> "(DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I f <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: i <br /> PHASE II GROUT INSPECTION `- PHASE I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DA <br /> {yrs <br /> E H 1426 Rev. 1-74 1-74 2M <br />