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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR. OFFICE USE: 1601 E. Hazelton Ave._ S <br /> t ,ckton, Calif. <br /> Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 7-/J_6 Y <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued //-.;�s"7? <br /> (Complete In Triplicate) <br /> Application 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 made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> Owner's Name 40,4� FloOd,�a,�J <br /> Phone <br /> Address <br /> ora �'� .�. IOU { City <br /> Contractor's Name �� Ile / m �; �o License # <br /> Phone <br /> TYPE OF WORK (Check) : NEW WELL 0�7 DEEPEN / / RECONDITION / / DESTRUCTION 1-7 <br /> PUMP INSTALLATION / / —PUMP�REPAIR / / PUMP REPLACEMENT /_7. ,ecrld <br /> Other / / -- <br /> DISTANCE TO NEAREST: SEPTIC TANK w SEWER LINES PIT PRIVY—� <br /> SEWAGE DISPOSAL FIELD ,/®Q CESSPOOL/SEEPAGE PIT -�__- OTHER <br /> PROPERTY LINED PRIVATE DOMESTIC WELL =!R' PUBLIC DOMESTIC TELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial � <br /> Cable Tool Dia, of Well Excavation <br /> Domestic/private �� Dri.11.ed ` Dia. of Well Casing �' <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation _x___ Gravel Pack Depth of Grout Seal <br /> Cathodic Protection L Rotary Type of Grout <br /> Disposal Other '` -• "-_ �. <br /> Other Information <br /> Geophysical _ Surface Seal Installed B - <br /> //I <br /> PUMP INSTALLATION: Contractor <br />------------- <br /> - ; TYAe of Pump <br /> --------- H.P. <br /> { <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: + <br /> / / State Work" Done <br /> lES•TRUCTION OF WELL: Well Diameter <br /> De s c r i-b-e--Mat-erial-and-Proned 'rue - Approximate Depth F <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 wel.l 'constructi.on. 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 />'RIOR TO GROUTING AND A FINAL INSPECTION. <br />'IGNED <br /> _ TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) -- <br />'RASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY � / <br /> ODIT10NAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION PHASE II FrNAL INSPECTION <br /> INSPECTION BY �` DATE ,r ? INSPECTION BY DATE <br /> E H 1426 Rev- 1-74 o.77 _ 2M <br />