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�jf SAN JOAQUIN LOCAL%HEALTH DISTRICT <br /> FOE OFFICE USE: / 7 1601 E. Hazelton Ave.: ..,Stockto +� <br /> n, Calif. <br /> Telephone:.: , (209) 466-6781 V <br /> APPLICATION FOR WELL_CONSTRUCTION<.,OR PUMP PERMIT Permit No. J42Q4,/ <br /> 4 <br /> THIS PERMIT. EXI?IRES l YEAR, <br /> FROM-.DATE.:ISSUED; Date Issued ,/ <br /> -(Compl.et.e In•Tripl•icate) ` <br /> Application is .hereby.,made: to the San Joaquin.Loca1 Health Dis.tricttfor a permit to construct <br /> and/or install the work herein described. T' his .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 - L /�/ CENSUS.TRACT <br /> : -.- t:- i- -- <br /> Owner's Name S ..l O.GQ <br /> ::� _.Phone 9/� 3`� 1;�?,— • <br /> I+ Address L City <br /> [ Contractor's Name License; #2k5^7�/ Phone4W <br /> TYPE OF WORK-(Check) NEW WELL/ / DEEPEN / / RECONDITION' /—/ ' DESTRUCTION <br /> PiJMPINSTALLATION '/ / PUMP REPAIR / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC•TANK SEWER LINES; PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT` OTHER <br /> f PROPERTY LINE _y PRIVATE_DOMESTIC A4ELL' PUBLIC DOMESTIC WELL D <br /> INTENDED USE--i- - ,---«TYPE OF WELL--- �---'CONSTRUCTION<SPECIFICAT--IONS v . <br /> Industrial b -Cable Tool Dia. 'oC Well Excavation <br /> -Domestic/private Drilled Dia. of :Well Casing (� <br /> Domestic/public ' '_ '.Driven Gauge of Casing f <br /> Irrigation [� <br /> g F. 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: J / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 6 - Approximate Depth-_, <br /> Describe Material. and Procedure O r <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' A FINAL INSPECTION. <br /> SIGNED TITLE r-, <br /> ..PtW PL FRSE SIDE) <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> f APPLICATION ACCEPT Y lrran�z DATE <br /> ADDITIONAL COMMENTS: --- <br /> i :PHASE II GROUT INSPECTION PHAS III/FINAL INSPECTION <br /> INSPECTION j BYE . DATE INSPECTION BY DATE�T <br /> AeAf <br /> E H 1426Rev. 1-74 , p�`°��� *,, , r.�l,�i ,.�.��: r r,7C6� / , <br />