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�7 <br /> vii/ SAN JOAQUIN LOCAL HEALTH DISTRICT f -5 3 d <br />' FOR OFFICE USE: 1601 E. Hazelton Ave., ' StbAton, Calif. <br /> Telephone: (209) 466 .6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 29_Zsal <br /> THIS PERMIT :EXPIRES 1`YEAR FROM DATE ISSUED Date Issued//- ,Y' <br /> (Complete In Triplicate) <br /> Application'is hereby made „to the San Joaquin..Local,,klealth 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,;rhe San Joaquin Local- Health District. <br /> .TOB ADDRESS/LOCATION (d L• fir" CENSUS TRACT <br /> Owner's Name Phone <br /> Address �. ��-. ..�'o 9 .,._.- City <br /> W4QD5 1NfL , DRILLING <br /> Contractor's Name License ��,Zy�,Phone ,�y ' <br /> . <br /> 0311, <br /> Foi ; <br /> TYPE OF WORK (Check): IN LLAEEPEN /_7 RECONDITION DESTRUCTION /-7 <br /> PUMP INS� /?TION PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK 1a SEWER LINES PIT PRIVY ,�f"� <br /> SEWAGE DISPOSAL FIELD J,0 CESSPOOL/SEEPAGE PIT �_ OTHER ¢- <br /> PROPERTY LUNE -- PRIVATE DOMESTIC WELL ' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial, Cable Tool Dia. of Well Excavation IZ2 " <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation ' . Gravel Pack Depth of Grout Seal G <br /> Cathodic Protection Rotary Type of- Grout <br /> Disposal. - . Other Other Information � <br /> Geophysical Surf ace Seal Installed By: <br /> i <br /> PUMP INSTALLATION: - ---Contractor <br /> Type of PumpH•P• 2_-_. <br /> PUMP REPLACEMENT: <br /> / / State Work Dane ' <br /> . _ l <br /> REPAIR: /� State Work Done <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 •regulat,ingwell 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- an& belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A� FINAL INSP CT ION. <br /> M SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I w <br /> OR DEPART T USE ONLY <br /> APPLICATION ACCEPTED BY C -.evi� DATE :l/ -1 7 e <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION f PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE _ /-1O �,� INSPECTION BYE DATE _, <br /> E H 1426 Rev. 1-74 ' 1-74 214 <br />