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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OF'r ICE <br /> USE: 1601 E. Hazelton Ave. , '80ekton, Calif. <br /> Telephone: (209).:,,,466=6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> , THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued R ' '77 <br /> I (Complete In Triplicate) •y <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 Z11 Tp S CENSUS TRACT nGt-132 y7 <br /> Owner's Name /� Phone <br /> } I l� <br /> J Address _ k 7 �, �T`Ge��.� L� city _Ga.ca1 <br /> Contractor's Name $a�n 'oat�uir� PUMP CO. - License #3/©,37 Phone <br /> C-ii <br /> -[RrP{SlV1r vT� 1 .. nkur Cn-} <br /> ]Lodi, Cal;fcrnicl <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN / / RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION -/ /;'t PUMP REPAIR / UMP REPLACEMENT /7 <br /> Other / / - " -4 S .� <br /> DISTANCE TO NEAREST: SEPTIC TANK -.SEWER LINES PIT PRIVY � <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE .PIT OTHER (n <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 /> Domestic/,public Driven='° = Gauge of Casing <br /> Irrigation -=*:Gravel,:Pack. _k;; :. .Depth .of Grout Seal <br /> Cathodic Protection Rotary Type of Grout r- _ <br /> Disposal . Other Other Information S <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ~ <br /> Type'hof Pump H.P. <br /> PUMP REPLACEMENT: / / !'State Work Done <br /> PUMP .REPAIR: : _ x_. /T ,Work Done _A�/d(0m. _,0 �tlJsi� <br /> DES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> i 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,-Califorxiia 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 /> f PRIOR TO GROUTING AL INSPECTI <br /> G� <br /> TITLE <br /> SIGNED <br /> San Jo igu'sn_ PLIMI) Co. <br /> D ; T PLAN ON REVERSE SIDE) (Division of �an�J uqu1n1l0pl ur Cel) I' <br /> FOR DEPARTMENT USE ONLY 1 IN azxzra.sser, o <br /> PHASE I 1,14PI, eclali."n[q 5721� <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTI PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ;7 DATE <br /> E H 1426 Rev. 1-74 <br /> 3/76 2M <br />