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SAN JOAQUIN LOCAL'.HEALTH DISTRICT <br /> FOR!OFFICE USE: 1601 E. Hazelton Ave, ,.,Stodkton, Calif. <br /> Telephone: (209) 4666781 <br /> APPLICATION FOR, WELL CONSTRUCTION OR PUMP PERMIT Permit No. meq_ X7641 <br /> I THIS PERMIT,EXPIRES 1' YEAR,,FROM DATZ ISSUED Date 'Is'subd -Zp-,74- <br /> (Com <br /> plew <br /> 74- <br /> (ComPletc r In Triplicate), <br /> Application'is hereby made to the San Joaquin Local..Hea3:th.l.Tlistrict.--for- a -permit toy-construct <br /> and/or install the work herein described. -This, applkcation,.Is, made .1n compliance with San'Joaquin <br /> County pOrdinance. No. ,142. and../fthe Rues and :Regulations of the- -San .Joaquin Loca1 Health- District. <br /> JOB ADDRESS/LOCATION I o 0 A �-• u, CENSUS-, TRACT - <br /> Owner Q s Name T` 1V1 iflo -, .._ ---: Phone 73 e- <br /> Address' City /VIII�' tL ��4N�p <br /> u <br /> Contractor's Name ., License- !� �Phone d' 1.5_:7Q <br /> TYPE. OF WORK (Check): NEW WELL '_& DEEPEN -7 RECONDITION /7 DESTRUCTION /-7 o , <br /> _PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /? <br /> then 1 / IdL� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - - PIT PRIVY. <br /> SEWAGE DISPOSAL FIELD .CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE.- -PRIVATE DOMESTIC WELL' Y'PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS.. . <br /> Industrial Cable Tool Dia. of Well Excavation �'- fi <br /> . .Domestic/private Drilled Dia: of Well Casing _f .0 , ` <br /> Domestic/public Driven - Gauge of Casing ��. ,P ,• <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout' <br /> Disposal Other r Other Information, <br /> Geophysical. -Surface Seal Installed BY: Qm V cmpe.6 <br /> 77 <br /> PUMP INSTALLATION: :Contractor <br /> gType of Pump H.P. <br /> PUMP REPLACEMENT: I/ % State Work Done <br /> PUMP !REPAIR: r�/? State Work Done <br /> ESTRUCTION 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 FIFTBEN'DAYS <br /> after completion of my'�work on a new. well-, I will furnish the .San.Joaquin Local Health District a <br /> s <br /> 'WELL DRILLERS REPORT of the well and notify them before putting.the.�well in.use.. The above <br /> information is trice to��the•best of- my knowledge -and belief. I 'WILL"CALL FOR'A -GROUT INSPECTION <br /> PRIOR TO'GROUTING AND A FINAL INSPECTION... . f <br /> SIGNED , TITLE <br /> dp (DRAW PLOT PLAN ON- REVERSE -SIDE <br /> .FOR.DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY7 DATE <br /> ADDITIONAL COMMENTS: ' <br /> PHASE II GROUT INSPECTION PHASE <br /> I INAL INSPECTION <br /> INSPECTION BY DATE _INSPECTION BY DATE =5 <br /> �� E H 1426 Rev, I-7iE 1-74 2M <br />