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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE�!OFFICE USE: 1601 E. Hazelton Ave. ; 'St,6'Ckfon, Calif'. <br /> Telephone:Y (209) eG66=6781 <br /> f APPLICATION -FOR WELL CONSTRUCTION OR PUMP. PERMIT Permit No. 74 - ff <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED. Date Issued /� -�S-7 <br /> :-�c�-_ 7v;•1 F—' •24- (Complete In .Triplicate) /.3 <br /> Application ie hereby made to San Joaquin Local.Health_District for a permit to construct <br /> and/or install the work hereiiv described. This. application. is made in compliance with San Joaquin <br /> County 0 inane No. 1862 '.th ]Rules d Regulatioagsof the an Joaquin Local Health District. <br /> JOB ADDRESS-/LOCATION: ENSUS TRACT <br /> Owner's Name ��7VyL/9. 1/iJ Phone <br /> Address 2� n_o City <br /> Y•' oatractar's Name �L v /`9 License -379Phone �� ' <br /> TYPE OF WORK (Check) : ._NEW WELL /? DEEPEN -7 RECONDITION /-' DESTRUCTION /? <br /> PUMP INSTALLATION / j PUMP REPAIR PUMP REPLACEMENT' %T <br /> Other ! I <br /> r� <br /> .DISTANCE TO NEAREST: SEPTIC UNK SEWER LINES . PIT PRIVY ` ` V) <br /> SEWAGE °DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL— PUBLIC DOMESTIC' WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF.WELL <br /> Industrial c^ . _.,. Cable\Tool Dia. of Well Excavation - <br /> Domestic/private Drilled Dia. of Well Casing <br /> r Domestic/public Driven Gauge of Casing <br /> Irrigation It Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 11 Rotary Type of Grout ` <br /> Disposal ,_. 0 Other r Other Information ' <br /> Ik Geophysical Surface Seal Installed BY: <br /> PUMP ,INSTALLATION: Contractor - -� <br /> Type of Pump H.P. .'". <br /> PUMP REPLACEMENT: / / (State Work Done <br />�'"'P��REPAIR;�""^`�"'""'""'�"'�'�'�"S`tate Woik`•Do e - - <br /> 2ES TRUCTION OF WELL: Well Diameter 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 /> r 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 GROUTING AND A FINAL INSPECTION. <br /> ¥ SIGNED - Cn� .r tw�J TITLE Y <br /> i (DRAW PLOT PLAN ON REVERSE SIDE <br /> FO DEPAR USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY lel. DATE <br /> ADDITIONAL COMMENTS: t _` <br /> PHASE II GROUT INSPECTION'", PHASE III4EINAL.INSPECTION <br /> INSPECTION BY _;DATE INSPECTION' BY DATE <br /> � i <br /> 1-74 2M <br /> E H 1426 Rev. .1-74 <br />