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SAN JOAQUIN LOCAL HEALTH DISTRACT i <br /> FOF OFFTCE"USE: <br /> 1601 E. Hazelton Ave , , Stock `on, Calif. C � <br /> Telephone : (209) 46676781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.] <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued j'24L,27 <br /> GG�, <br /> Applicatiopihereby made to the San (CompleteJoaquin La alrHealthtDistri.ct 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/LOCATIONA C <br /> CENSUS TRACT <br /> t Owner's Name �( / <br /> k k Phone <br /> Address t- r-4 <br /> City <br /> Contractor's Name x <br /> LicenseW-4-.?Z`Phone �N5 <br /> 1 <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN/_/ RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT 1-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC ;TANK SEWER LINES PIT PRIVY �� b <br /> SEWAGE �DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ OTHER CI'� <br /> PROPERTY LINE - PRIVATE DOMESTIC'WELL �� PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECT <br /> IndustrialFICATIONS <br /> 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 <br /> Cathodic Protection Rotary- V Type of Grout <br /> Disposal Other Other Information <br /> Geophysical # 'J <br /> Surface Seal Installed B : � <br /> PUMP INSTALLATION: X Contractor_ _ /Ab g ,• (�. <br /> Type,'of`Pump <br /> PUMP REPLACEMENT: P <br /> / / State Work Done <br /> PUMP .REPAIR: / f State/Work Done <br /> DESTRUCTION OF WELL: ,X Well Diameter <br /> �� scribe Material and P ocedur Approximate Depth <br /> r � <br /> ' 4 w G' <br /> I hereby agree to comply withla laws and regulations o 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�oflthe well and notify them before puttingthewell in use. The above <br /> information,is true o .the st of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO,." NG AND F INSPECTION. <br /> SIGN Vii: TITLE <br /> n (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ON <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATES --7 <br /> PHASE II ' OU DATE i1VSPEC N PHASE III FI AL INSPECTION <br /> INSPECTION BY / INSPECTION BY DATE <br /> i <br /> r <br /> E H .142.6 Rev. • 1-74 6!77 o�n <br />