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SA <br /> M �.. N -IOAQUIN LOCAL -,gEALTH'DISTAICT <br /> FOfi OFFICE LISE-: r 1601 E.s Hazelton Ave. Stdc'kton, Calif. <br /> Telephone: (209)' 466-6781 _ <br /> ' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit—No. <br /> tK-� THIS PERMIT EXPIRES 1 Yj§AR FROM DATE ISSUED Date Issued <br /> r (Complete In Triplicate) r <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/LOCATION, 1 " CENSUS TRACT <br /> Owner°s Name Phone <br /> Address <br /> City ? <br /> Contractor's' Name ' _ License L1,jZd.jp <br /> TYPE OF WORK (Check): NEW WELL /77-16EEPEN /-7 RECONDITION '/? j <br /> DESTRUCTION / , <br /> PUMP INSTALLATION PUMP. REPAIR / PUMP: REFLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE 00 hIVATE DOMESTIC WELL.— PUBLIC DOMESTIC WELL <br /> INTENDED USE. TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial jam--Cable Tool Dia. of Well Excavation �- <br /> , Domestic/private Drilled Dia. of Well Casing -� � <br /> Domestic/public Driven Gauge of Casing J14L <br /> Irrigation B Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal <br /> Geophysical Other Other Information I <br /> Surface Seal Installed By:J-7 <br /> PUMP INSTALLATION: Contractor 0/4'rrr? <br /> Type of Pumpa�"z. ... H.P.- <br /> PUMP <br /> •P.PUMP REPLACEMENT: iState Work Done <br />'-PUME'AIR: �^N/-7 <br /> State Work Donewi � - <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-beat of my .-knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TOGROUTING- D FINAL INSPECTION. <br /> SIGNE � � <br /> TITLE .` <br /> � - (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE' <br /> ADDITIONAL COMMENTS: ,: k; <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION- BY -� DATE4zasz2D--� <br /> E H11426 Rev. 1-74 c c <br /> 1_74 <br />