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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stpkton, Calif. <br /> Telephone : (20)' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 7:,/�6 <br /> !� THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) � 0_�/ 7 <br /> � 7Y <br /> Application is Aereby 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 /> 2.1317 S. 1-f A-e-e-oc­6 , w <br /> JOB ADDRESS/LOCATION j "If. /U Q CENSUS TRACT <br /> Owner's Name o� � 3 ) �(,(� ph <br /> one <br /> Address <br /> City <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check) : NEW WELL �ll' DEEPEN /_% RECONDITION / / DESTRUCTION /_7PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT J-7 <br /> Other/ <br /> DISTANCE TO NEAREST: ' SEPTIC TANK t SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD - CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL - <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public W Driven Gauge .of Casing <br /> Irrigation _� Gravel Pack Depth of Grout. Seal -- t <br /> Cathodic Protection _`1 Rotary Type of Grout -- 1 <br /> Disposal. Other Other Information F <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: ContractorIit�lYf <br /> Type of Pump _ /�,,ff��_ H.P.j, _a _ <br /> PUMP REPLACEMENT: / / State Work DL629 <br /> PUMP .REPAIR: / / State Work Done r 1" *. <br /> DESTRUCTION OF WELL: Well Diameterk ~' <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with all-laws and- regulat•rons 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 GROUTI AND A FINAL INSPECTION. <br /> SIGNE - TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE)� _ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 2_Z_L77 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIO PHASE,h;4/FINA9 INSPECTION <br /> INSPECTION BY DATELZ 7 <br /> INSPECTION BY DATE .. <br /> E H 1426 Rev. 1-74 1177 _ 2M <br />