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r _ SAN JOAQT'IN..4 AL;HEALTH DISTRICT <br /> F08 r'OFFICE USE: 1501 E. Hazelton.Axe '`S't ckton Calif. <br /> Telephone::C;'(209) 466.-X6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT,`EXPI'RES 1 YEAIL ELM: DAT 'ISSUED ;} : Date Issued <br /> (Complete In Triplicate)..,., <br /> Application •18 hereby -made to the San Joaquin-'Local,,HeaDth strid'ti for: a permit. tb1,;cbinattuct <br /> and/or-install the..work herein described, ,-,This application!: s mada iwrompliance'iai�th` San joaq'ufti <br /> County-Ordinance No 4862 and th6.r 41e:s ana; Regul-gt ons, of .tY:e Sanr'J�aquf�n :LocallHealth.-Distiict. <br /> JOB- ADDRESS/LOCATION 1_.xGENS[I5' TRACg :,. " <br /> Owner's Name Aj Phone <br /> Address - �, City <br /> °` <br /> Contractor's.Name ' " = ;_� <br /> License #' `"-'Phone `w <br /> TYPE OF WORK (Check): NEW WELL DEEPEN7'/7 RECONDITION / . DESTRUCTION`S ' <br /> RUMP INSTALLATION / / PUMP REPAIR /_ .PUMP REPLACEMENT J� 4 <br /> Other 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK �_ SEWER` LINES PIT PRIVY _ <br /> SEWAGE DISPOSAL FIELD ` CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE.- PRIVATE 56RESTIC WELL � PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ' Cable Tool Dia. of Well Excavation <br /> _ Domestic/private Drilled,...;. ...•; ,:. Dia: of-Well- -Casiog <br /> Domestic/public, Driven t. Gauge ,of, Casing <br /> Irrigation Gravel Pack Depth of Grout Seal' . <br /> Cathodic Protection Rotary -Type of­.Grout <br /> Disposal Other Other Information- <br /> Geophysical `, ' 'Surf ace Seal Installed By:•,M ,,b/ <br /> PUMP INSTALLATION: Contractor .. <br /> Type of Pun* { . ! H.P. <br /> PUMP REPLACEMENT: /_/ tate ,Work <br /> PUMP,� �. Done <br /> -7 <br /> � rkpone,'.REPAIR: State.Wae <br /> } r <br /> �..�,�.�..._ --. • ::�..�.." �:-T.... - <br /> PES1RUCTION OF WELL: Well. Diameter 7 Approximate Depth 1p2 k <br /> Describe .Material: and 'Pocedure <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 MtEEN DAYS <br /> after completion of my work on a new well, .Iewill 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 besti of- my...knowledge- -and belief. I'WILL CALL"FORA GROUT" INSPECTION <br /> PRIOR TO GRO TING AND A FINAL INSPECTION. ; ,...- <br /> SIGNED TITLE <br /> {DRAW PLOT PLAN ON REVERSE SIDE <br /> „ FOR DEPARTMENT USE ONLY .. , <br /> PHASE I ; <br /> APPLICATION ACCEPTED,.BY <br /> ADDITIONAL COMMENTS: . .... .. .... .;,. <br /> PHASE' II 'GROUT 'INSPECTIONPHASE III FINAL INSPECTION' , <br /> INSPECTION BY DATE INSPECTION 'BY DATE JG- * <br /> S�E H~.1425 Rev. I-7.4.. <br /> 174 214 <br />