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>. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave'; "5fockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> lrJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 z / _y yCLSUS TRACT <br /> Owner's Name 7t�_ � Phone <br /> Address I (F4G . City _4wX2 <br /> Contractor's Name d License # oDA/3/3 Phone <br /> S TYPE OF WORK (Check) : NEW WELL/b/-' DEEPEN / / RECONDITION /_T DESTRUCTION /_ <br /> PUMP INST—ALLATION / J PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other , / / — —. -- <br /> F — <br /> DISTANCE TO NEAREST: SEPTIC TANK Z_ SEWER LINES PIT PRIVY Ofdwel- <br /> , � SEWAGE+DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OVER ,SQ <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 /0? <br /> y-� Domestic/private I Drilled Dia. of Well Casing F // <br /> Domestic/public I Driven Gauge of Casing / aa-1 <br /> ' — Irrigation f Gravel Pack Depth` of Grout Seal <br /> ' Cathodic Protection Rotary Type of Grout <br /> Disposal ;1 Other Other Information ' f <br /> Geophysical `�1 Surface Seal Installed By: <br /> It{ <br /> PUMP INSTALLATION: Contractor <br /> Type Iof Pump H.P. <br /> PUMP REPLACEMENT: / / !S tate Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter ''""'" '` `' Approximate D th"0W77Y62_ <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 TOG UTING AND A FI);AL INSnCTIOIJ. <br /> r SIGNED ITLE It <br /> i D L T PAN ON REV' SE SIDE) <br /> DEPARTMENT USE ONLY <br /> r PHASE I <br /> APPLICATION ACCEPTED BY DATES4 . <br /> r. ADDITIONAL COMMENTS: Z c ` <br /> PHA II O T. INSPECTION PHASE"I ,/F , I4/INSPECTI <br /> INSPECTION BY ;DATE ' INSPECTION BY `,,PATE <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 _ <br />