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SAN JOAQUIN LOCFtockton, <br /> DISTRICT <br /> FOS'OFFICE USE: G14 1601 E. Hazelton Ave Calif. <br /> Telephone: `t,209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 4--.79- <br /> (Complete <br /> (Complete In Triplicate) <br /> Application i he by 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 nd Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone "� � - - <br /> Address ---' <br /> City <br /> Contractor's Name s l License # 6?��Y/ 'Phone!5� ?/01=x/ <br /> TYPE OF WORK (Check)! NEW WELL /" DEEPEN '/7 RECONDITION /7 DESTRUCTION /-7PUMP INSTALLATION / PUMP REPAIR'/? PUMP REPLACEMENT— j <br /> Other L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PAPPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 11� <br /> Domestic/private Drilled Dia, of Well Casing , .:;- � <br /> Domestic/public Driven Gauge of .Casing - ./ a \ <br /> Irrigation _ Gravel Pack Depth of Grout Seal <br /> Cathodic Protection _� Rotary Type of Grout <br /> Disposal OtherOther Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> pUNP REPLACEMENT: . / / State Work Done <br /> - PUMP REPAIR: /7 State Work Done <br /> REESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> Y hereby agree to comply with all laws and regulations <br /> mP Yof the San Joaquin Local Health Distric <br /> ,and the State of California pertaining to or regulating well''construction. Within FIFTEEN DAY <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District <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 ftUTING AND A FXXAL INSP ION. <br /> SIGNED LE <br /> DRAW P T P ON REV SIDE <br /> R DEPARTMENT USE ONLY S <br /> PHASE I � � <br /> APPLICATION ACCEPTED <br /> ADDITIONAL COMMENTS: <br /> E II GROUT INSPECTION PHASE III AL INSPECTION <br /> INSPECTION 8Y DATE - / INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 4/75-.-2M <br />