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SAN, JOAQUIN,:•LOCAL'=HEALTH DISTRICT - - --- <br /> FOArOFFICE USE: 1601 E. Hazelton.Ave:.%S-'Sto'ckton, Calif. <br /> Telephone : .(209) 466-6781 <br /> APPLICATION FOR.;WELL -CONSTRUC,TION OR PUMP PERMIT Permit No. Tct—.z_474o tJ <br /> THIS= PERMIT EXPIRES•, 1 YEAR•Abk D"ATE'l ISSUED t.Date.Issued'!{ <br /> r�- (Complete.In Triplfca e),`.-1 0 <br /> Application is hereby made 'to the 'San Joaquin.Local Heal.th Diatr.ictt.fors a.permit to- construct <br /> and/or install the,work"herein"descr.ibed.,, This application .U-madef1re .compliance with San Joaq uii <br /> County,Ordinance.. Na: 1862 and the ,Rules and Regulation's mf the Saxia Joaquin Local Health District, <br /> spa-`7 i Lr �'o�S . ,I.; .3.110 <br /> JOB ADDRESS/LOCAtION <br /> . y ,� ' CENSUS'TRACT <br /> + r _ r M <br /> Z. <br /> iYe• . µ., .E.. {fro :1.3�w •.-4. /vr.. iE <br /> Owner's Name Phone <br /> Address <br /> Jj�/ - = _ �,. , .w ^ City" <br /> Contractor's Name. I E License. Phone g3j;. 7J'74 <br /> P+�rr --+ -•-6v ._. '. �aa.r.v'�: ...-� _�. _a - F ..y4--y—..�. .+N.-. � � -'.r <br /> TYPE OF WORK (Check): NEW,WELL /7 7bEEPEN /_• RECONDITION /_ DESTRUCTION ! <br /> PUMP. INSTALLATION / '/ PUMP REPAIR -7 PUMP REPLAcm <br /> 1 <br /> Other / �. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ' :PIT, PRIVY. .. ..; <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT 'OTHER <br /> PROPERTY LINE --PRIVATE DOMES <br /> . TIC WELL PUBLIC DOMESTIC WELLW� <br /> INTENDED USE i TYPE OF WELL g CONSTRUCTION SPECIFICATIONS <br /> Industrial '+ Cable Tool ; Dia. <br /> !of Well Excavation <br /> Domestic/private Drilled Dia. ,of Well Casing, J - <br /> Domestic/public Driven Gauge of�Casing, D 494_ . <br /> Irrigation Gravel Pack Depth of Grout ,Seal <br /> Cathodic Protection' s Rotary Type of .Grout' ° <br /> Disposal Other Other Information 9 <br /> Geophysical_, Surface Seal Installed B : <br /> E ,. <br /> PUMP INSTALLATION:` Contractor <br /> a Type. of Pump ----- -- <br /> H.P. <br /> PUMP REPLACEMENT: 1� / /. State Work Doe { <br /> PUMP'`.REPAIR: n w -w- /-7. -State Work_'Done""'""""`" <br /> E&TRUCTION`OF WELL: WeDiameter proximate Depth. <br /> Diw' - f <br /> .�-- 74 � Ap . �..� <br /> Describe Material and Procedure ­,, <br /> I hereby agree to comply with all las and regulati ris the aquaL Local Hb*11th Dist�ricVU <br /> and the State of California pertaining to or-regulat.iug well 'construction. Within FIFTEEN DAYS— <br /> after <br /> AYS—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 TO GROUTING .AND A FINAL INSPECTION., <br /> SIGNED I , k TITLE &644J 4 <br /> F (DRAW PLOT PLAN ON REVERSE SIDE <br /> sFOR.DEPARTMENT USE ONLY } <br /> PHASE I <br /> APPLICATION ACCEPTED BY f A DATE ¢ j <br /> ADDITIONAL- COMMENTS: F a <br /> PHASE II GROUT I PECTION `,. PHASETI <br /> INSPECTION BY w DATE INSPECTION BY DATE <br /> -E. H 1426 Rev. I-74_ ..�.r .-.. _ - <br /> 1 % — 1-74 2M <br />