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SAN JOAQUIN LOCAL'HEALTR DISTRICT <br /> FORIOFFICE USE: 1601 E. Hazelton Ave. , ,Stoekton, Calif. <br /> Telephone: x. (209) 466:-6781 <br /> f APPLICATION FOR WELL'CONSTRUCTION OR PUMP PERMIT Permit No-2 7;30 <br /> THIS PERMIT EXPIRES Z-YEAR: FR0m DATE ISSUED Date Issued 3 of-,27 <br /> 1 (Complete In 'Triplicate) <br /> # Application is hereby made to the San Joaquin -Local Heal- th Uiatrict for a permit to construct <br /> and/or insiall. the-work herein described.- This applicati:on.-is made in compliance with San Joaqui <br /> County Ordinance No: 1862 and the Rules and Regulations ,of .the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION. tv T Je CENSUS TRACT <br /> Owner's Name Phone <br /> Zat <br /> Address <br /> City A e n', <br /> i Contractor's Name �7 <br /> �ly License -.2j Jp�D Phone <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN /?_RECONDITkON /7 DESTRUCTION /_7 L7 INSTALLATIONS PUMP REPAIR /,,,,,,PUMP REPLACEMENT %f <br /> Other /_ — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> 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 V <br /> Industrial ' Cable Tool Dia. `of Well Excavation <br /> Domestic/private E Drilled Dia. of Well Casing <br /> Domestic/public DrivenGauge of Casing <br /> Irrigation — Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> ' Disposal Other Other Information <br /> Geophysical <br /> Surface Seal Installed B <br /> r PUMP INSTALLATION: Contractor <br /> 7,D1. f <br /> Type ;of Pump H.P. f <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .ItEPAIIti= •;- - / tate W rk Done.�� <br /> f ESSTRUCTION OF WELL: Well Diameter; } <br /> 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 en a new well, I will furnish the San Joaquin Local Health District a <br /> I WELL DRILLERS REPORT of the well and notify them before putting the- well in use. The above <br /> information is true tothe-best-af <br /> PRIOR TOG ,my-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> UTING AND FIN INSPECTION. <br /> r SIGNED .010' TITLE <br /> ;. (DRAW PLOT PLAN ON REVERSE SIDE) <br /> F'OR. DEPARTMENT USE ONLY <br /> PHASE I <br /> t APPLICATION ACCEPTED BY . <br /> DATE Z ,7 77 <br /> ADDITIONAL COMMENTS <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br />? INSPECTION BY DATE INSPECTION BY DATE -�. -)/4 <br /> I ? E H 1426 Rev. 1-74 <br />