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v SAN JOA <br /> QUIN LOCAL;:HEALTH DISTRICT <br /> FOR 'OFFICE USE: 1601 E. Hazelton ,Ave: ,."Sf6ckton, Calif. <br /> Telephone: (2 09) 466.=6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7��1«6fo <br /> THIS PERMIT EXPIRES :I-YEAR.; FROM.DATE ISSUED Date Issued <br /> (Complete..In -Triplicate) — <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 the San Joaquin Local Health District. <br /> JOB .ADDRESS/LOCATION 3 e-2 <br /> CENSUS TRACT <br /> Owner's Name !-. <br /> Phone .j <br /> Address " © $ `7.4E; City <br /> Contractor's Name/L License #2S 52 60 Phone <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN -/-7. RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION / PUMP REPAIR 0 PUMP REPLACEMENT /—f <br /> y : ,Other <br /> DISTANCE TO'INEAREST: SEPTIC TANK. SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD- _ CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY -LINE - PRIVATE-DOME STIC WELL PUBLIC DOMESTIC WELL \(� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS (("' <br /> Industrial Cable Tool Dia. of Well Excavation X11 ' <br /> -..:. Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic ProtectionRotary Type of Grout <br /> —Disposal ' <br /> Other � . Other Information <br /> Geophysical, Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor 5 <br /> Type of Pump :. H.P. U <br /> PUMP REPLACEMENT: C7 State Work Done F 'I <br /> PUMP �REPAIR: /X7 State Work Done r <br /> ES;TRUCTION OF WELL: Well Diameter Approximate Depth__ <br /> Describe Material and -Procedure u. <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 furaishithe -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 GROUTING AND A F N INSPECTION. ' s <br /> SIGNED 526 TITLE _ <br /> T PTM4 Z, <br /> REVERSE SIDE �._ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I r <br /> APPLICATION ,ACCEPTED BY DATE I <br /> ADDITIONAL 60MMENTS: S <br /> PHASE II GROUT INSPECTION PHASE I/FINAL INSPECTION <br /> INSPECTION BY DATE F_INSPECTION BY DATE <br />'� E H 1426 Rev. 1-74 <br />