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SAN JOAQUIN LOCAL HEALTHDISTRICT <br /> FOR('OFFICE USE: 160] E. Hazelton Ave Stocktori,`talif. <br /> Telephone: (209) 466=6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7.5-- A4191-0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7/7-7.s-. <br /> (Complete in Triplicate) ..�.. <br /> Application' is hereby made to the San Joaquin Local .Health_Dist�ricf for a permit to construct <br /> and/or install the work herein described, .- This application • s'-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 <br /> ze __2L K eCENSUS TRACT <br /> Owner's Name , Phone 37Z Ze7f Address - r- city <br /> Contractor's Name r_ License Phone <br /> r <br /> TYPE OF WORK (Check): NEW W9LL /? DEEPEN /_7 RECONDITION /7 DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP;REPAIR 'J./ PUMP REPLACEMENT e <br /> Other %// T <br /> DISTANCE TO NEAREST: SEPTIC•'TANKx _SEWER LINES PIT PRIVY t <br /> SEWAGE DISPOSAL FIELD CESSPOOL/.SEEPAGE PIT , OTHER <br /> PROPERTY LINE - PRLVA'TE DOMESTIC WELL ' PUBLIC DOMESTIC WELL <br /> INTENDED USE .TYPE OF-WELL I CONSTRUCTION SPECIFICATIONS <br /> Industrial {Cable*Tool Dia. of Well Excavation . r` <br /> Domestic/private :1 ., Dril-led _,�:.-- v Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation `hi : Gravel Patk'4� Depth of Grout Seal <br /> Cathodic Protection ii '> Rotar3r'_• i Type of Grout <br /> Disposal Othe r µ Other Information <br /> Geophysical ": Y Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of -Pump H.P. i <br /> PUMP REPLACEMENT: <br /> 71 State Work Done 1 ,� <br /> F <br />'�PUNB.'-•'REPA'IR• �.* .��,/�.�-;Srta'te-�ior�'Ri)�r'ne-� �- —- _ ,. --_ � <br /> ES;TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with�'all laws and regulations of the San Joaquin Local, Health Distric <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAY; <br /> after completion of my work on 'a new well, I will furnish the San Joaquin Local Health District <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-, . my knowledge and belief. I WILL CAL OR GROUT INSPECTION <br /> PRIOR TO GROUT)A AND A FI I ECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE\SIDE <br /> FOR DEPARTMENT-USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT NSPECTION PHA54 JWFKNAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - j' _�J <br /> =E H 1426 Rev. 1-74 Y .:. <br />