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SAN JOAQUIN LOCAL4HZALTH DISTRICT NG <br /> FOF�;OFFICE USE; 1601 E. Hazelton Ave:;-5{fckton, Calif. <br /> ' Telephone: (209) 4b6-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7Z,A 2d <br /> THIS PERMIT EXPIRES 1 YF,AR FROM DATE ISSUED Date Issued <br /> (Complete InlTriplicate) <br /> APplication is hereby 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 and Regulations of t n Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> F Owner's Name �GCf —phone <br /> Address <br /> CitY.. <br /> Contractor's Name <br /> License # RPhone ( j <br /> TYPE OF WORK (Check): NEW WELL ,/W DEEPEN/7 RECONDITION /7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / PUMP REPAIR -/? PUMP REPLACEMENT /7 i <br /> Other /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ; <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ' <br /> 4 PROPERTY LINE - PRIVATE DOMESTIC WELL" PUBLIC DOM . <br /> INTENDED USE TYPE OF WELL <br /> Industrial CONSTRUCTION SPESTIC WELL <br /> ECIFICATIONS <br /> Cable Tool Dia. of Well Excavation A0 <br /> i Domestic/private - Drilled Dia. of Well Casing Ar <br /> Domestic/public Driven <br /> Irri axion-..-_ �. ._Geuge of GroutCasin �— <br /> _• -g --� f�ravel P�c1c Depth of- Grout Seal <br /> Cathodic Protection _� Rotary Type of Grout r <br /> Disposal <br /> Other Other Information , <br />��• _Geophysical t <br /> F_ Surface Seal Installed B <br /> PUMP INSTALLATION: ContractorAvjw <br /> p y F <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: <br /> / / State Work Dane <br /> PUMP ;. . R <br /> /7- State ..Work .Done <br /> ' L -✓.�..-)/=a`L L�,��C� !�TRUCTION OF WEL52, <br /> cimtelr�y . Approximate Depth JU <br /> be Materigl and Poc d`ure i <br /> �r <br /> 5r <br /> I _hereby agree to comp 'EIi`all laws and regulations of the San Joaquin Local Health District s <br />'and' the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> aftercompletion of my work on a new well, I will furnish the San Joaquin Local Health District al : <br /> WEL#I, DRILLERS REPORT of the well and notify them before putting. the..we11 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 G OUTING AN NAL I ECTI N... <br /> SIGNED <br /> TITLE <br /> DRA PLOT LAN ON •REV SE SIDE <br /> " <br /> PHASE ,I FOR DEPARTMENT�� U ONLY + <br /> SPP CATION ACCEPT BY <br /> ADDITIONAL COMMENTS: DATE ' i2 - <br /> PHASE I G OUT INSPECTION PHA I AL INSPECTI N <br /> LNSPECTIQN BY DATE INSPECTION, DATE <br /> . <br /> E H 1426 Rev. le I <br /> -74 �� P �.. <br /> ;� <br />