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;, y SAN JOAQUIN LOCAL:HEALTH DISTRICT <br /> ' FORlOFFiCE USE: 1601 E. Hazelton -Ave.. Calif. <br /> Telephoner (209)_465=5781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.'c7rL1 5 !J <br /> THIS PERMIT EXPIRES l ,YEAR.FROM DATE ISSUED Date Issued Ao- �Jtj <br /> . . (Complete .In Triplicate) <br /> .Application is hereby made to the San Joaquin- Local Realth District for a permit to construct <br /> and/or,instail 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, 66 6 '.' ✓ CENSUS TRACT <br /> Owneris' Name �i^� s+.S/ - - - - Phone <br /> Address - _ ._ M.� . City <br /> Contractor's Name r G License #,,?0f) Phone •aG <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN -7 RECONDITION /-7 DESTRUCTION a <br /> PUMP INSTALLATION I .I PUMP REPAIR ,/� PUMP REPZACEMENI f T <br /> Other '/% _ _ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE ,DISPQ AL FIELD CESSPOOL/SEEPAGE PIT //G / OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> i Industrial Cable Tool Dia. of Well Excavation Q <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 I Rotary Type of .Grout sr- <br /> Disposal I Other Other Information <br /> Geophysical i Surface Seal Installed By: _ <br /> PUMP INSTALLATION: Contractor / . <br /> Type 'of Pump f H.P. "T <br /> PUMP REPLACEMENT: / / Istate <br /> Work Done <br /> PUMP `REPAIR. IState- Work Done"` - <br /> tl . <br /> PES 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 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 <br /> WELL DRILLERS REPORT of the well and notify them before putting—the— well in-use.. The above <br /> information is. true a best of my wledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUTI D E ON". A <br /> SIGNED _ TITL <br /> Mtt (DRAW PLOT PLAN -ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED: _: /C DATE�p <br /> ADDITIONAL COMMENTS c'. -a - t <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE �{'j _/� �7y/ " INSPECTION BY DATE <br /> � }+ i. E H 1426 Rev. 1-74 1-74 2M <br />