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f SA.v J0A(,'!U1X LOCAL HEALTH DIS-MPIrT <br /> USE 1641 E. ii�*e.el,toa Ave. , Stuc;,'�Lon, Cal.it <br /> Tele=phana: (209) 466-6781. t �� <br /> APPLICATION POR WELL CONSTRUCTION 01t PUMP PERMIT Permit NoO-� �f <br /> 1 r$ <br /> _. _.. THIS PERMIT EXPIRES 1 YEAR FROM I?:{TI ISSUED Date Issued � � <br /> (Complete In Triplicate) ' <br /> :acion is hereby made to the San Joaquin Local Ilealtil District for a permit to construct <br /> install the work herein described. This application is made in compliance with Sen Joaquin" FSS <br /> 'i,(;rdinanca No. 1862 and the Rules and Regulations of the San Joaquin Local gealth District <br /> )DRFSS/L0CATION CENSUS TRACT €; <br /> r°s Name . a •� p1 PhoneN. <br /> o City LJA <br /> License IlSAC. Phone Ali <br /> �c'tor s Na�i11@. '-. <br /> Ali <br /> V. <br /> NIN (N " IV t,: <br /> t I~tol (Ctt ek): VIEW WILL DuPEN /� RECONDITION /� DESTRUCTION <br /> _ x, kis , <br /> PUMP INSTA.IAATION PUMP REPAIR / / PUMP REPLACEMENT /� J g ,r� s <br /> Uther . / ..� �.. <br /> Ns'E TO FEAREST: SEPTIC 'SANT( ZOAL SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER , o <br /> F'ROP!,ItTY I.,INr -- PRIVATE DOMPSTIC WELD. —....» PUBLIC I)QMESTIC WELL <br /> _T,I3`IFi�#7FD L►SE TYPE Or WELL CONSTRUCTION SPECIFICATIONS <br /> ild'ustria'l Cable Tool Iiia. of Well Excavation <br /> o Sticlprivate Drilled Din. of Well Casing <br /> J <br /> ?�oma:s is/public � Driven Gauge of Cgsing k <br /> G <br /> Irrigation Gravel Depth of Grout Seal <br /> 8 l Pk De� _� p �Srt» <br /> t cathodic Protection Rotary Type of Grout a k ` <br /> b. ffy a <br /> Disposal Other Other Information <br /> I Geophysical Surface Seal Installed By: . t <br /> ITNSTALLATI ON: Contractor .. 'Ak <br /> Gt <br /> Type of Pump <br /> !REPLACE-- L/ State Work Done <br /> !REPAIR: State Work Done ; <br /> ._. .. <br /> IUC_TION OF WELL: Well Diameter _ Approximate Depth <br /> Describe Material and Procedure <br /> ic,by agree to comply with all laws and roaulat.ions, of tits San .Ionquin Local Health District <br /> jte State of California pertaining to or regulating well construction. Within 1:IFTEEN DAYS -, <br /> completion of my work on a now well, I will furnish the Sun Joaquin Local Health District a <br /> ir)RILLERS fUEPORT of the well and notify them before putting the well in use. The above i <br /> ration is true to the best of my knowledge and belief. I WILL. CALJ1 FOR A GROUT INSPE'CT.ION <br /> TO GRO NG -kND AL 'L ZION. <br /> rIi _ TITLL <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> `LCAT1ON ACCEPTED BY r - -- �•_-- _ DATE S',-"Of <br /> 'C l ONAL CQM� ENT S: <br /> PkASf's LI GROUT INSPECTION PLiASE III/L-'INAL INSPECTT,ON 4 s <br /> L E .OtN� <br /> `:ClrION 13Y �1_ DATE INSPECTION <br /> 61177 2sa <br /> it 106 Rev— 1-74 <br /> , 1-74 <br />