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9 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FWOFFICE USE: 1601 E. Hazelton Ave:, Stbckton, Ca1"if'; <br /> Telephone: (204) 466-67-81 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 =/_5`A <br /> THIS PERMIT EXPIRES 1 YEAR• FROM DATE ISSUED Date Issued <br /> , yI (Complete In Triplicate).•: I <br /> Application is hereby made t. the San Joaquin Local Health District For a permit to Construct k <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 'lthe-'�.San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION,,- 6,z f 1 T/w, 0 I '- 5 l i 46 zz CENSUS TRACT <br /> �+,+ <br /> Owner 18 Name + � ,'. �-. (, .yq Phone <br /> Address';-' -. :_ -f._ `` ;. � �� _, = City "" TM . <br /> Contractors Name . A/! S [ /� s 6 5 Phone, 12- <br /> Y km2 <br /> S c� IVi l''� License �� O <br /> TYPE OF WORK (Check): . NEW WELL /7 DEEPEN / ' RECONDITION /77 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAI-R�/>7 T PUMP REIIA•CEMENT f7 <br /> Other/sC/,S.1q,�..� ��.Ry---.S',�:R--�_ i A/' <br /> DISTANCE TO NEAREST: SEPTICITANK` 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 /> - <br /> Drilled Domestic/private Dia of Well Casing 4 Esr <br /> _.. Domestic/public :Driven- Gauge of Casing t <br /> Irrigation— i Gravel Pack Depth of Grout Seal i. � <br /> Cathodic Protection J1 Rofary Type of Grout <br /> Disposal n Other Other Information <br /> Geophysical 'Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor , . <br /> Type of Pump A.P. 1C <br /> - PUMP REPLACEMENT: / j S tate Work Done <br /> PUMP !REPAIR: / State Work Done �, G <br /> A S�TRUCTION OF WELL: Well :Diameter Approximate Depth 1 <br /> m 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'an 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 knowl dge and belief I WILL CALL FORA ROUT INSPECTION <br /> PRIOR TO 2ROUTIN2 AND A FINAL INSPEC.LION. . <br /> SIGNED A/ TITLE <br /> >t F DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE "` <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE<..II.I/F.INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY .;% DATE ` f <br /> 'I E H 1426 Rev. 1-74 ` 1-74 2M <br />