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SAN JOAQUIN LOCAL HES ock on <br /> DISTRICT <br /> I'oF� Calif- <br /> OFFICE USE; 1601 E. Hazelton Ave. , 466-5781 6-�13�✓� <br /> Telephone: (209) Permit No• <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PENT i <br /> l Date issued 6�?6 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATEIS <br /> ' SUED <br /> (Complete In. Triplicate). a permit <br /> hereb made to the San Joaquin Local Health c��sta�de inrcompliancetwithnSinuJoaquir <br /> Application is Y ' application <br /> ` <br /> and/or install the work herein described. This app <br /> NO- 1862 and the Rules and Regulations applica of the San Joaquin Local Health Districts <br /> County Ordinance N CENSUS TRACT <br /> JOB ADDRESS/LOCATION <br /> i . Phone 41lo 16"10 <br /> 1. owner's Name 611,A111111 <br /> �' r. <br /> City <br /> Address 60 <br /> Q License 'L� "-. Phone -JSi7 <br /> Contractor's Name <br /> PE TOFY WORK {Check): NEW WELL_ DEEPEN '/? REGONDZRIO�P DESTRUCTION <br /> f <br /> k PUMP INSTALLATION / I PUMP REP <br /> ! Other <br /> SEWER LINLrS PIT PRIVY <br /> DISTANCE TO NEAREST: SEPTIC TANK CESSPOOL/SEEPAGE PIT -' OTHER <br /> SEWAGE DISPOSAL FIELD PUBLIC-DOMESTIC ME TS IC WELL <br /> s PROPERTY LINE - PRIVATE DOMESTIC WELL <br /> INTENDED USE ; TYPE OF WELL CONSTRUCTION SPECIFICATIONS. <br /> - <br /> Industrial Cable Tooj ' Dia. of Well Excavation ' 9 <br /> Drilled Dia. of Well Casing <br /> Domestic/private — <br /> Domestic/public Driven Gauge of Casing <br /> Gravel Pack- Depth of Grout Seal <br /> Irrigation a of Grout <br /> Cathodic Protection Rotary Type <br /> Disposalr Other Other Information <br /> Geophysical Surface Seal Installed BX. ' <br /> j PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: / / -State Work Done <br /> PUMP .REPAIR: /- ;State Work Done <br /> DESTRUCTION OF WELL: . Well Diameter 7 - 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 an a new well, I will furnish the San Joaquin Local Health Districl <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 INSPECTIOA <br /> PRIOR N D INSPECTION. <br /> TITLE <br /> SIGNS _ <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE III FINAL INSPECTION <br /> PHASE II BOUT INSPECTION INSPECTIONBY DATE 7 - <br /> "k INSPECTION BY 1 DATE <br /> : . 2M <br />