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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 7—FO—F--'OFFICE USE: j 1601 E. Hazelton Ave= ;-Si�bckton, Calif. <br /> } !/ Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT . Permit No. 7,6- a Y6 U <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby madeto 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 Joaqui <br /> County Ordinance No. 1862 'and the Rules and Regulations of the San Joaquin Local Health District. <br /> r' . <br /> JOB ADDRESS/LOCATION E! 6 CENSUS TRACT . <br /> Owner's Name :i Phone ' <br /> Address <br /> Citya .� <br /> Contractor's Name ' r� License �� Phone , Q. <br /> TYPE OF WORK (Check) ; NEW WELL DEEPEN/% RECONDITION /_/ DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIR /—/ PUMP REPLACEMENT /- <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK �JO� SEWER LINES 47D , PIT PRIVY <br /> SEWAGE DISPOSAL FIELD fW' CESSPOOL/SEEPAGE PIT OTHER SO <br /> t PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL R <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 Driven Gauge of Casing <br /> •' Irrigation Gravel Pack Depth of Grout Seal ;.!i-� <br /> _ <br /> Cathodic Protection ; Z Rotary Type of Grout <br /> Disposal . Other Other Information CA6 (� <br /> Geophysical Surface Seal -Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> �. PUMP .REPAIR: r :/ /, State -Work°Done <br /> c Opt <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> pth <br /> Describe Material P ocedure <br /> t_7 ereb reeto com 1 w.ithall3aws egu'lations' of �C a-San Joaquin Local Health District <br /> g -t . . .prY <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 GR UTING AND-.,AFLNAL INSPUTION , <br /> SIGNED JAI ITLE <br /> 1 D W E PLAN- ON REVNSE SIDE) f..: <br /> F EPAR MENT USE ONLY <br /> PHASE I <br /> APPLICATION. ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT: INSPECTI N PHASEI 1/ 149 ECTION <br /> INSPECTION BY ©LULL '17- DATE INSPECTION BY DATE <br /> � E H 1426 Rev. -I-74 , . . <br /> 3/76 2M <br />