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f � <br /> SAN JOAQUIN LOCAT. I1F.A1,T1� hl S.,!R IC1 <br /> FU1; UE'FICE U5E:� 1601 E. HAzeIton Ave. Blackfan, Cnllt . <br /> Telephone: (207) Sh6-6781 <br /> APti VATiON FOR WFLL CONSTRUCTION nR I'll?U' PEP..'TT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FR%1 DATE ISSUE'S Dnte Iaeued <br /> (Complete In Triplicate) <br /> Application is herei-y mr. l^ to the Snn Jonquln Locnl Ilenith District for a permit to eonstr•r-.t <br /> and/or install the w-%k herein described. This application is made in Compliluce with Ilan Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the Sen Joaquin LotAl Health District. <br /> JOB ADDRESS/LOCAION 1 _ j/I J,-A CENSUS TRACT <br /> 7� i+ner'a Name T ,��I A, Phone <br /> 'ddress / 7 <br /> City Z AjZ, EiV <br /> Contractor'n Name _ License II j �'gZ Phone <br /> TYPE OF WORK (Check): NEW WE1,1. DEP,PEN /7 RECONDITION ,/7 DESTRUCTION <br /> rum INSTALLATION /-7PUMP REPAIR /j PUMP REPLACOM <br /> her �--/ _. <br /> DISTANCE TO NEAREST: SEPTIC TANK / SEWER LINES O PIT PRIVY / <br /> SEWAGE DISFOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ` <br /> _ PROPERTY LINE - PRIVATE DOMESTIC WELL — PUBLIC DOMESTIC WELL- <br /> I <br /> INTENDED -uSE T' OF WELL CONSTRUCTION SPECIFICATIONS �) <br /> Industrial Cable Tool Dia. of Well Excavation �11 <br /> Domeatic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Cauge of Casing <br /> Irrigation !; <br /> - g Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout CJ I <br /> Disposal Other Other Inforantion I <br /> Geophysical Surface Seal Installed Bps t,c / A- <br /> PUMP INSTALLATION: Contractor 1 1C - <br /> Type of Pump -- H.P. <br /> PUMP REPLACEMENT: L/ Stnte! Work Done <br /> 1 PUMP REPAIR: <br /> /-7 Stare Work Done <br /> 1.)ES TRUCTION or WELL: Well Dinmeter 12, �� Approximate Depth / <br />-` Describe aterial and Procedure _z <br /> -. � 1 <br /> I hereby agree to comply u; 'i all int, And rlegulntions of the San Joaquin Local Health District <br /> And the Stnte of California pertnining 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 n-tify them before putting the well in use. The above <br /> fr.formntion is t ue to the best of my knowledge nni belief. I WILL CALL FOR A GROUT' INSPECTIO <br /> PRIOR TO G_TUTIA9--A0 .A FINAL INSPECTION. i <br /> 1c�l'D (T TITLE t^Loy �' <br /> + (DRAW PLOT I'LAtI UN REVERSE SIDE <br /> _ <br /> MASE I FOR DEPARTMENT USE ONLY <br /> � <br /> AfPI.TrATM111 ArrrrTrn nv ' _ _- _ <br />