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7-.r <br /> SAN JOAQUTN LOCAL HEALTH.DISTRICT ' <br /> 1601`E �iieltan Avo.� S�ockton, CaliF": <br /> tisL=d: NFICE'USE� _ y ,. <br /> Telephone: (209) 4667,6781 <br /> APPLICATION FOR WELL-CONSTRUCTION OR PUMA''OPERMI'T Permit No. <br /> f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made.7to the San Joaquin Local Health District for a permit to construct 1 <br /> and/or install the work herein described. This application is ,made in compliance with San Joaquin ' <br /> Countv_O.r.d.i-nance No. 1862 and,-the-Rules and Regulations of the San Joaquin Local Health District. <br /> 46 7—,;790 4,13 <br /> 2- 014- Gqo,), iir CENSUS <br /> JOB ADDRESS/.LOCATION � ��o��' i�/ '_� <br /> PhoneOwner.'s.Name " r <br /> _ City <br /> Address <br /> Contractor's Name <br /> License # O�.3z hone <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN / / RECONDITION / / DESTRUCTION /_7 ^' <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> Other / / C <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD �--- CESSPOOL/SEEPAGE PIT �^ OTR <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL-c2— <br /> INTENDED <br /> ELLcINTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> �. <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack. Depth of Grout Seal O <br /> Cathodic Protection ^ N- Rotary Type of Grout _ZZS?C- <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> r <br /> f <br /> PUMP .REPAIR: /--State .Work Done - - - - <br /> ----- <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> C 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 REP of the well and notify them before putting the .well in use. The above <br /> informaMUTINGJOD-A <br /> is tr e t the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR T FINAL INSPECTION: <br /> ? Ift1m a. <br /> SIGNED ` , TITLE <br /> 11 DRAW Pt .T PLAN ON REVERSE SID <br /> �. FOR'^.,DEPARTMENT USE ONLY <br /> PHASE I ° <br /> APPLICATION ACCEPTED BY--•-- DATE,'. a� 8 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSP CTIO '° P SE II/FINAL INSPECTION <br /> . INSPECTION BY DATE <br /> INSPECTION BY DATE ,• ' <br /> 3/76 2M <br /> E H 1426 1 Rev. 1-74 <br />