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_ a SAN JOAQUIN LOCAL'IUaALTH DISTRIff <br /> FO ;OFFICE USE: 1601 E. Hazelton:Ave,.; 4Stocktazx, Callf a`,: ; <br /> y, t <br /> E Telephone: .'(249) 466=6781 <br /> 1;. APPLICATION FOR WELL CONSTRICTION OR PUMP PERMIT Permit No. Z�_ <br /> THIS PERMIT EXPIRES 1 YEAR-.FROM DATE­ISSUEVDate Issued <br /> #: :t i.� (Complete .In Triplicate)' r <br /> Application is hereby made to the San Joaquin .Local llealth District- fo-r:: a' permit to construct <br /> and/or,install..the work herein described. --,This appli'cation.,is made=•,in. compliance with San Joaquin <br /> County Ordinance No.. 1862 ar�d the Rules and Regulations .-of.,the ,San Joa4uim Local Health District. <br /> II <br /> JOB ADDRESS/LOCATION �� d. CENSUS TRACT <br /> Owner's Name Phone <br /> m <br /> K, t <br /> Address="'" ­_ .� <br /> Contractor's..Name - License #��7. 9�Phone - 3 .3 <br /> TYPE OF. WORX!! (Check):.. NEW-WELL DEEPEN 'I— RECONDITION I� DESTRUCTION /_7 � <br /> i� PUMPIINST LATION _E1PUMP REPAIR /_7 PUMP REPLACEMENT 1 J - <br /> R. Other I 77- <br /> DISTANCE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ' 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 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private , Drilled Dia. of Well Casing ' <br /> Domesilc/publi.c Driven Gauge of Casing. 1044e .31 <br /> Irrigation Gravel Pack Depth of Grout, Seal <br /> Cathodic Protection Rotary Type --of Grout <br /> Disposal - Other Other Informati n <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type: of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: /71-State Work Done +` <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 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 TING ANDA FINAL INSPECTION. <br /> SIGNED M1 TITLE <br /> - (DRAW PLOT PLAN ON REVERSE SIDE <br /> i <br /> OR DEPARTMENT USE, ONLY <br /> .� <br /> PRASE ;Ii-I <br /> APPLICATION .ACCEPTED I BY, •V DATE I ` `�!� <br /> ADDITIONAL COMMENTS: <br /> PHASE PHASE IIFINAL INSPECTI Il <br /> F INSPECTION. BY­ ' 1 DATE INSPECTIOW BY DATE <br /> .«��ywr.ww�``�' - 5 i. . a _ .., ..,-.... -..w�.... �._.•�.. �'}S'. .,.wr- ..... .w.r�. ..,.. - - .... ... <br /> `� E H 1426 Rev. 1-74 1-74 2M <br />