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SAN JOAQUIN LOCAL':IdEALTH DISTRICT <br /> FOR!OFFICE USE: -1601 E. Hazelton Ave. , 'St66kton, Calif. <br /> Telephone: (209) 466-6781 a <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 3/Q <br /> .3 . - , <br /> THIS PERMIT EXPIRES 1 YEAR FROM. DATEISSUED•. --Date Issued <br /> (Complete .In Triplicate)' : <br /> Applieation is hereby made to the San Joaquin Local .Health District for a permit to construct <br /> and./or install. the .work herein described. This application,is :rade in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations,oft.the- San-Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION - p2s ' CENSUS TRACT <br /> a <br /> Owner°s Name Phone �g- �', j <br /> Address e . � 7S L 1700,0e� ...,. City s ;SC 94o -�W <br /> Contractor's Name -77A L4oru 4-S a License #r2 O 10 Phone $zt.�b?Q7 <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /_7 RECONDITION /-' DESTRUCTION /_7PUMP INSTALLATION / / .. PUMP REPAIR /V PUMP REPLACEMENT f7 <br /> Other / 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY : <br /> .SEWAGE DISPOSAL FIELD Ci's POOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial t Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. 'of Well Casing <br /> Domestic/public a Driven Gauge .of Casing <br /> Irrigation A Gravel Pack Depth of Grout Seal , <br /> Cathodic Protection 11 Rotary Type -of' Grout-- <br /> Disposal r Other Othep_.Information <br /> Geophysical a Surface Seal Installed By: ! <br /> PUMP INSTALLATION: Contractor, ..- . <br /> Type of Pump H.P. <br /> PUMA' REPLACEMENT: / / State Work Done <br /> PUMP _ _ _ P <br />-- REPAIR': <br /> """'`� �Stte Work Done i4 Did �, a2 y' 1�u vG" <br /> ES�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 /> and the State of California pertaining to or regulat.ingvell .construction. Within FIFTEEN DAYS s <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 FORA-GROUT INSPECTION <br /> PRIOR TO GROR.IINC OD A KN. kgSPECTION. <br /> SIGNED - TITLE <br /> t <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR D >XR T USE ONLY <br /> PHASE I /� <br /> APPLICATION ACCEPTED 'BY r U/ • DATE <br /> ADDITIONAL COMMENTS '1 <br /> PHASE II GROUT INSPECTION PHAag UI4EINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION- BY DATE e,0� �J <br /> l E H 1426 Rev. 1-74 1-74 2M ,. <br />