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SAN JOAQUIN LOCAL-HEALTH DISTRICT <br /> FOA(OFFICE USE: 1601 E. Hazelton Ave`:-, ;StVAton, Calif. <br /> Telephone: . (209) 466'47' 81 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7s=17 71A�v <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 /> County Ordinance No. 1862 and the ,Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION71 -� ''CENSUS TRACT <br /> Qwner <br /> •rs Name 7i(&r)v)95 .' 1�9z Phone 's <br /> ? <br /> .Address �C� �� �d ��. r/����g <br /> City <br /> Contractors Name�r7?50- 311 ' .. -_ il�'3?3 Phonia d�01�� <br /> License <br /> F <br /> TYPE OF WORK (Check); NEW WELL /_]" DEEPEN /7 RECONDITION /-7 DESTRUCTION 17 y j <br /> PUMP INSTALLATION L-7 PUMP REPAIR REPLACEMENT <br /> Either E7 <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 <br /> Domestic/private Drilled Dia., of Well Casing <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 BY: <br /> PUMP INSTALLATION: Contractor i <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: <br /> 1 . /./ State Work Done <br /> PUMP :REPAIR: State Work Dote �� <br /> ES.'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 /> 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 <br /> .(DRAW PLOT PLAN ON REVERSE SIDE) <br /> E ffFO DEPARTMENT.USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ' DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II-GROUT INSPECTIOR PHASE III FINAL INSPECT ON <br /> INSPECTION BY „DATE INSPECTION BY [°� DATE f"/y ,� _ <br />} ' E H 1426 Rev. 1-74 <br /> 1-7G ?M <br />