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SAN JOAQUIN LOCAL HEALTH DISTRICT <br />;, F OFA;uFFICE USE: <br /> /1601 E. Hazelton Ave. , kon, Calif. <br /> Telephone; (209)- '466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. , s7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplica �; . ` <br /> Application is hereby made to the San Joaquin Local Health N. 11 <br /> or 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 fhe -San Joaquin Local Health District.. <br /> f2�sa-,�. C�r�r�s ,QQ • .t , <br /> JOB ADDRESS/LOCATION - .F-CEN U5 TRACT <br /> Owner's Name 610 <br /> A�ERkone <br /> Address City . . <br /> Contractor's`Name f, 1,2License 13 P14one - <br /> TYPE OF woRx Check): . _ _ �-, <br /> ( NEW WELL: DEEPEN.'/? .RECONDJUNK, 01__DESTRUCTIONJ7_ - j <br /> { PUMP INSTALLATION / / PUMP REPAIR. /_7 PUMP. REPLACEMENT 17 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK / o ' SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ OTHER 1 <br /> ' PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS >j <br /> Industrial - - Cable Tool Iia. of Well Excavation / ' ? � <br /> Domestic/,private Drilled Dia, of Well Casing J-f <br /> Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection _/� Rotary. Type of Grout C, & <br /> Disposal Other Other Information " <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> # Type of Pump <br /> H.P. <br /> _ ; r <br /> PUMP REPLACEMENT: C/ State Work Done Q �tjM P mil 52FA �- <br /> PUMPIREPAIR: State Work Done <br /> ` � -M`r� <br /> DESTRUCTION OF WELL Well Diameter <br /> Approximate Depth 4 <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 AmGROUT INSPECTION <br /> PRIOR TO GRO TING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> RP!FLICATION ACCEPTED n <br /> �- DATE `�� <br /> ADDITIONAL COMMENTS: ik�'da & Ai� <br /> PHASE II OROuT INSpECTION PHASE III' FINAL INSPECTION <br /> INSPECTION BY DATE INSP TIONBY DATE — -'77 <br /> A1,9 <br /> yE H 1426 RPv- I_7A ¢ <br />