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7.3 <br /> * --SAN JOAQUIN LOCAL. HEALTH DISTRICT/ fa <br /> NOR-OFFICE USE: ' 1601 E. Hazelton Ave. ,'"StbcR.ton, Calif. <br /> -Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.17 <br /> " 7 THIS PERMIT EXPIRES 1 <br /> YEAR "FROM DATE ISSUED <br /> Date Issued�(��f <br /> A (Compl77 <br /> ete In Triplicate) 1 _ <br /> pplica-tion is hereby made .tolthe 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 "4 <br /> County Ordinance No., 1862. and� the Rules -and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> ° D CENSUS TRACT <br /> Owner's Name r` Sa. a <br /> PhonE a <br /> Address R / <br /> City <br /> Contractor's Name ---- <br /> License #` Phone -S <br /> E . <br /> A. <br />;TYP,E,r:OF WORKS(Check)-: ANEW WELL /�'/ _DEEPEN RECONDITION„/_7,,,.DES.TRUCTION_/? ;_.. <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other — <br /> DIS TANCE_TO:NEAREST: SEPTIC TANK . .122 - <br /> -- _ j . SEWER.LINES- PIT PRIVY <br /> SEWAGE DISPOSAL.II,ELD CESSPOOL/SEEPAGE PIT ---OTHER \ t <br /> PROPERTY LINEGD PRIVATE DOMESTIC WELLX4& 4 PUBLIC DOMESTIC WELL <br /> .INTENDED USE TYPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATTONS <br /> Cable Tool Dia, of Well Excavation �0 <br /> Domestic/private Drilled , ; Dia. of Well Casing � <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of'Grout .Sea <br /> 1 <br /> `Cathodic Protection ! Rotary Type of :'Grout <br /> Disposal Other Other Information k <br /> Geophysical ! Surface `Seal Installed B <br /> PUMP INSTALLATION; Contractor. Y { <br /> Type of Pump <br /> H.P'. <br />'UMP <br /> REPLACEMENT: /—/ State Work Done ; <br />'UMP 'REPAIR: / / State- Work Done <br /> LEE&TRUCTION OF WELL: Well Diameter ' <br /> Describe?Material and Procedure Approximate Depth- <br /> hereby agree to comply with all laws and regulations of the Nan Joaquin Local� .Health District <br /> end the State of California pertaining to or :regulating well ''construction. Within FIFTEEN DAYS -� <br />,fter completion of my work on a new well, Iwwill furnish, the San Joaquin Local Health District a <br />'ELL DRILLERS REPORT of the well and not'fy ihe'm before utting the -well in use. The above <br /> nformation .is true to the Vqbiowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> RIOR T ING D A FIN P <br /> IGNED <br /> TITLE _,V <br /> (DRAW PLOT PLAN ON "VERSE SIDE) ' r <br /> IIASE? T�� t . w�LL FOR DEPARTME USE ONLY <br /> �9('f J�f it <br /> PPLICATI1. ON ACCEPTED BY - DATE <br /> DDITIONAL COMMENTS: AL,21b7- <br /> PHASE 'II GROUT INSPECTION <br /> VSPECTION BY PHASE III/FINAL INSPECT N <br /> DATE INSPECTION BY Z9- 3-,7-,7ff DATE <br /> E 4'1426 Rev. 1-74 <br />