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SAN JOAQUIN LOCAL 'HEALTHL%13ISTRICT <br /> FOVOFFICE USE: L1641 E. Hazelton Ave;',. xSt'acktbft';: Calif. <br /> Telephone: , (209) , 4W-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;?K_ &2)d <br /> THIS3.PERMIT EXPIRES 1 YEAR..FROM:,DATE ISSUED Date Issued 2� <br /> �3 (Complete.In Triplicate) f - <br /> Appiication 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�ls 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- CENSUS TRAGI <br /> �.4 T <br /> Owner's Name " Phone <br /> Address 3 f' 2- `a' City d A/ <br /> Contractor's Name <br /> License # 26fL Phone 4,d <br /> TYPE OF;WORK (Check): NEW WELL '/-7 DEEPEN 17 RECONDITION /? DESTRUCTION /_ <br /> PUMP INSTALLATION /7 PUMP REPAIR PUMP REPLACEMENT % f <br /> w Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ' <br /> PROPERTY .LINE -- PRIVATE -DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I Cable Tool Dia. of Well Excavation <br /> Domestic/private ADrilled Dia. of Well Casing d <br /> Domestic/public Driven Gauge of Casing t ' <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary -Type of Grout 1 <br /> Disposal Other Other Ynformation <br /> Geophysical Surface Seal Installed BY: j <br /> PUMP INSTALLATION: Contractor e; <br /> ' Type of Pump _ - H.P. <br /> PUMP REPLACEMENT: / / - State Work Done <br /> PUMP .REPAIR: State Work Done <br /> ES-TRUCTION OF WELL: Well Diameter Approximate Depth � <br /> Describe Material and Procedure - <br /> . <br /> I hereby'agree 'to`cdmply with all laws and regulatiohe 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 <br /> WELL DRILLERS REPORT of the well and notify them before-putting. the. well in-use.. The above i <br /> information is true to the best of- my knowledgeand ,beiief:' I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. � <br /> SIGNED TITLE <br /> "(DRAVPLOIr PLAN ON REVERSE SIDE <br /> ' FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED,BY-_ DATE <br /> ADDITIONAL-COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ._ DATE 1,1 <br /> t E H 1426 Rev. 1-74 <br /> I-74 91U <br />