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} C�, L1.11 ^.„--,AN �JOAQUIN LOCAL HEALTH DISTRICT <br /> fOFS rOFFICE USE: 1601:,R.,: Hzelton 'Avd,.�- I5tdckton Calif. <br /> Telephone: r�'(209)_466- w <br /> 6781 J6-�89 <br /> I At APPLICATION 'FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EMIRES,1 1EAR,FROM.DATE ISSUED Date Issued <br /> =.� (Complete In Triplicate) i <br /> Application is hereby made to. the San Joaquin Local: Health District for a permit to construct <br /> anti/or install the work-herein described., in <br /> -compliance appl•icationmis made icompliance, with San Joaquin <br /> County Ordinance No.- 1862 anti tha RulesfandRegulations�of;the :San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �... s:'- CENSUS .TRACT i <br /> Owner's Name j _„._.. ....., _. Phone — 2 <br /> Address L' .- -- . City ns <br /> x <br /> Contractor's Name. #.:ZfJ O?Phoney <br /> IyF <br /> TYPE OF WORK (Check): NEW WELL /7-, DEEPEN /7 RECONDITION /? DESTRUCTION <br /> PUMP INSTALLATION PUMP REPAIR /� PUMP- REPLACEMENT <br /> other <br /> DISTANCE TO NEAREST: SEPTIC TANK .l.�..__r SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER r <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELLm PUBLIC DOMESTIC WELL ? �? <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial able Tool Dia. of Well Excavation A2,,yy \ <br /> a/Domestic/private Drilled Dia. of,mWell Casing ” <br /> ---Domastic/public- - Driven i Gauge•of,Casing <br /> Irrigation Gravel Pack Depth of Grout Seal. E <br /> Cathodic Protection Rotary Type of Groutm ,�, <br /> Disposal m Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION:- Contractor.--.. ,- ..- --�.---�»- --w---a------- �...,�.-.- ---- � <br /> Type of Pump. .rj. H.P. <br /> a PUMP REPLACEMENT: %SState Wo 'k Doqj�'e- , -_ y <br /> PUMP '.REPAIR: 1 /7 State Work'Done <br /> ,SES, RUCTTON OF WELL: Well Diameter 'r Approximate Depth ] <br /> f <br /> Describe•-Material and Procedure <br /> I hereby agree�to comp with;all laws and r gulations of the San aquin 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 /> f information is true to the-best-of my.knowledge and,belief. I WILL CALL FOR A -GROUT INSPECTION <br /> PRIOR TO GROUTING AND 44INAL XNSPEMMN, . <br /> I SIGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> ., <br /> PHASE I FOR DEPARTMENT USE.ONLY <br /> - � � . ,...,,_..,,•. <br /> APPLICATION ACCEPTED BY f_ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTI N _ _PHASE III FINAL-INSPECTI N <br /> INSPECTION-BY - DATE 2. ;�I INSPECTION-BY DATE <br />�� E H 1426 Rev. 1-74 1-74 2M <br />