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y---------- <br /> SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOB'OFF C SE: 1601 E. Hazelton Ave'.",Stockt6n, Calif. <br /> Telephone: ;' (209) 46,6-6781 . ' <br /> APPLICATION FOR WELL. CONSTRUCTXON OR- PUMP PERMIT Permit No. 7�,5-,46/� <br /> J U <br /> THIS PERMIT EXPIRES-1-YEAR FROM DATE ISSUED Date Issued <br /> (Complete .In Triplicate) <br /> Application is is hereby made to the San Joaquin Local Health -District for a permit to construct 1 <br /> and/or install the work herein described. This applicii <br /> ation is made in compliance with San Joaquin ; <br /> County Ordinance No. 18./62 and, the Rul -dtn Reguiatlons of `he San Joaquin Local Health District. <br /> JOB ADDRESS/LOCA I / � p� G �c- -z'l�rt CENSUS TRACT <br /> Owner's Name OLS' Phone <br /> Address ✓ .. at'aC� � �� Cit <br /> ��.a-3�- ' <br /> Contractor!s Name ��� ., License � Phoneme 9e�� <br /> TYPE OF WORK (Check): NEW WELL 1H DEEPEN/-7 RECONDITION /_7 DESTRUCTION /7 l <br /> PUMP INSTALLATION /—/ PUMP REPAIR /—/—PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TAN &W'-,r-- SEWER LINES PIT PRIVY I <br /> SEWAGEDISPOSALFIELD 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 <br /> Domestic/private Drilled .Dia. of Well Casing / <br /> Domestic/public Driven Gauge of Casing 0 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout 1�-l64 0r '70 1 y 19u <br /> Disposal Other Other Information j <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor .;Z?Z-1°7"%,9 ` J."'P S <br /> Type of Pump / Z,,2,17�2 0�v H.P. / <br /> PUMP REPLACEMENT: /1/ State Work Done <br /> PUMP-,'.REPAIR:- r/-;. /-,-St-a-te-.Work Done <br /> 4ES1RUCTION OF WELL: Well Diameter Approximate Depth <br /> DescribMaterial and Props ure _ <br /> I hereby agree to comply with all laws and regulations of the Sari Joaquin Local Health District j <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 /> SIGNED �- G � TITLE <br /> (DRAW PLOT -PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY /0 l i DATE 'I o)--9-7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE ;kjA/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION ByyDATE <br /> E H 1426 Rev. 1-74 1-74 2M <br />