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SAN JOAQUIN ,LOCA: HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave.A.. Stn�kton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-J43 42 <br /> Vj- <br /> THIIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued I-!?-7,,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 th-e <br /> Rules and Regulations of the San Joaquin Local Health District. <br /> 6 <br /> JOB ADDRESS/LOCATION J CENSUS TRACT <br /> Owner's�Name f Phone ' :z f <br /> Address t, /y*: . City <br /> Contractor's Name f 'Lcense # ag0�l3 Phone -- Q�/ <br /> { z i <br /> Ty_PE'OF`WORK' {Check) NEW WELL%� DEEPEN f /'RECONDITION / / DESTRUCTION/ 7 <br /> 4 PUMPIINSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> Other 17 <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 /> t. Industrial Gable Tool Dia. of Well Excavation <br /> JQ <br /> _ .Domestic/private Drilled Dia. of Well Casing <br /> "� Domestic/public Driven Gauge of Casing <br /> — s. ,:s ---•--y-=Gi=ave3�Park " `. �Dept�i�'of�Grnut�e'al: �.. - 7-- - =------- --. -- <br /> Cathodic Protection 47 Rotary Type of Grout � <br /> Disposal Other Other Information <br /> - Geophysical .. 'Surface Seal Installed By: <br /> PUMP INSTALLATION: Cont actor OAA� <br /> i Type, of Pump H.P. _ <br /> �L PUMP REPLACEMENT: / -/ ', state Work Done ' <br /> PUMP .REPAIR: / / State Work Done et= ._ <br /> ITES•TRUCTION OF WELL: Well; Diameter 3 S Approximate Depth <br /> Describe Material and Procedure <br /> 70 X�AA,4AJr]4A/dV,'P el.AIP O2 <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 UTING AND A• NAL SPECT ION. <br /> SIGNED TITLE <br /> PLAN ON EgIdT.RSE SIDEin <br /> ; <br /> FOR DEPARTMENT "TSE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECT;ON PHAS II /F AL INSPECTION <br /> INS' PECTIO4 BY DATE & INSPECTION BY ATE L <br /> Zf/ `,�, , ,� , -� �. - 376�"2M} E H 1426 Rev. 1-74 ; - , _-- <br />