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t;. <br /> rr <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT t� <br /> bi FO OFFICE USE: 1601 E. Hazelton Ave., •tb'ockton, Calif. <br /> Telephone: (209) 466-6781 �i� <br /> APPLICAT: 1N FOR WELL CONSTRUCTION OR PUNP PERMIT Permit No. 74/- S_ 7 � <br /> THIS PERMIT EXPIRES 'l YEAR-"OM :,ATE ISSUED Date Issued1 j.L- <br /> (Complete In Triplicate)' <br /> .Application is hereby made to the San Joaq%iin Local -Health,Tlistrict' for a pa'rmit-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 Regul.Uions of ;.:4e�Sa:r'Josquia Local`Health District. <br /> JOB ADDRESS/LOCAT.ION 1'' CENSUS TRACT' 4 <br /> Owner's Name Phone <br /> Addfebs 07 <br /> _.. . _ .. City <br /> Contractor's Name 1 License # Phone <br /> K' <br /> 'y TYPE OF WORK (Check): NEW WELL /-J DEEPEN /k7 RECONDITION /7 DESTRUCTION L-1 <br /> PUMP INSTALLACIONL7 PUMP .REPAIR /7 PUMP .REPLAC'aan - <br /> Other �� :, <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRI <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <* <br /> PROPERTY EINE - PRIVATE DOMESTICLL' PUBLIC DOMESTIC WLLL��.... <br /> INTENDED USE_ TYPE OF WELL CONSTRUCTION SPECIFICATIONS a � <br /> Industrial a Cable Tool Dia. of Well.,Excavation V <br /> Domestic/pAvate Drilled Dia, oT Wdli'Casing <br /> _ <br /> Dot estic/pubite Driven Gauge of Casing: <br /> _ IrAgation Gravel Pack Depth of Grout,Segl <br /> _ <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information : <br /> Geophysical Surface Seal Installed B : <br /> PUMP INSTALLATION:. Contractor . <br /> Type of. Pump , H.P. l� <br /> PUMP REPLACEMENT: L/ State Work Done <br /> PUMP .IMPAIR: L7 State Work Done';' j <br /> ESTRUCTIC-DI OF WELL: Well Diameter 1' Approximate Depth <br /> `t 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 FIFTEEW 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 /> PPIOR TO GROUTING AND A FINAL INSP'.X11ON, <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I , <br /> APPLICATION AC'JEPTED BY s- DATE <br /> ADDITIONAL COMMENTS: i <br /> PHASE II GROUT INSPFCTION PHASE I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DA <br /> �1 E N 1426 Rev. 1-74 1-74 2M <br />