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SAN JOAQUIN LOCAL HEALTH 'DISTRICT — -- <br /> _LOS rOFFICE USE: 1601 E. Hazelton Ave�, ,Stocktori, 'Calif. <br /> Telephone: (209)_466='6781 <br /> APPLICATION FOR WELL CONSTRUCTION. OR PUMP PERMIT Permit No. 11a <br /> + /THIS PERMIT EXPIRES 1.zYEAR .FROM- DATE ISSUED Date Issued S- <br /> ! (Complete In Triplicate) , <br /> Application is-hereby made to the San Joaquin Local Health District for a pewit to construct <br /> and/or install the .work`-,herein described. This application-is made in compliance with San Joaquin , <br /> Countrdinance,No.�1862...and the Rules and.;Regulations '�nf7the San. Joaquin Local Health District. <br /> S-23a.—t4 <br /> JOB ADDRESS/LOCATION, J t_-t f GAC CENSUS TRACT <br /> Owner's Name �l,N � � � � . ._ Phone <br /> Address city K d, �o R <br /> Contractor's Name 'vh� License # Phone 51 -1gS_L- <br /> TYPE-OF-WORK (Check) NEW WELL =/7 -DEEPEN /7Y RECONDITION /7 DESTRUCTION � <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT <br /> Other-/ / . . <br /> r f <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES -sPIT,PRIVY s <br /> SEWAGE DISPOSAL FIELD R CESSPOOL/SEEPAGE PIT OTHER ~ <br /> PROPERTY LINE 2.PRIVATE DOMESTIC WELLPUBLIC DOMESTIC WELL 1 . <br /> k INTENDED USE -- w TYPE OF-WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial " ' l Cable Tool Dia. of Well Excavation <br /> .Domestic/private 3 Drilled_; .: TT Dia. of Well Casing t <br /> Domestic/public !- —' Driven Gauges of Casing , <br /> k_ Irrigation - {.- 'GravelPack , Depth, of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other ! Other.-Information �. <br /> Geophysical Surface' Seal Installed By: <br /> PUMP INSTALLATION: Con_tractor d <br /> Type of Pu f <br /> • TYP � __..__��� -cis-� � � H.P. 1::�7 <br /> PUMP REPLACEMENT: /% State Work Done <br /> PUMP '.REPAIR: � � - <br /> L 7 State Work Done <br />­JDE_&TRUCTION-OF WELL: We31 Dfamete APprox ma a Depthf <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-best of my-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. . <br /> SIGNED y TITLE y <br /> (DRAW PLOT PLAN ON REVERSE SIDE) . <br /> OR DEPARTMENT .USE ONLY <br /> PHASE I <br /> APPLICATION ACCEP AL!N DATE Z3 • zz <br /> 4 <br /> ADDITIONAL COMMENTS: ;l. . <br /> PHASZ,,Xj4GROUT INSPECTION PHAU III F AL INSPECTI N <br /> INSPECTION BY 'DATE INSPECTION SY DATE <br /> E H 1426 . Rev. 1-74 <br /> ,I 1-74 2M <br />