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.N JOAQUIN LOCAL IIEALT?i D LSTRI T <br /> FOR OFF LCE USE: 1601 E. Hazelton Ave. , Stocxton, Ca-if. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,)- 3 71,0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ff_ L- 7y <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/LOCATIOON X': CENSUS TRACE <br /> Owner's Name p u 4 e— Phone <br /> Address / 2 Ta.< 7cr'. c r`M City <br /> Contractor's Name r/� �u �_7�1 License # �Phone VA1 -T.2 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_7PUMP INSTALLATION REPAIR /� / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY O . <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER rzz� <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL — PUBLIC DOMESTIC WELL — �1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing tks <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor_ �L e6/ _ w„ <br /> Type of Pump a H.P. U <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: State Work Done f1,11 rn ' - el) ///!i, i• •hr Pu <br /> pES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <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 furnish the San Joaquin Local Health District a <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 GR UTING AND A FINAL INSPECTION. <br /> SIGNED -t ? :.TITLE n ' <br /> (DRA PLOT PLAN ON REVZRSE SIDE) <br /> FOR DEPARTMENT USE ONLY Q <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 <br /> , <br /> Y°� <br />