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y. <br /> V SAN JOAQUIN LOCAL HEALTH LTSTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave'. , Stockt"n, Calif. 7 iC— f,37f <br /> Telephone: (209) 466•-6781 � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1.i0 7� ° <br /> fi d7 (Complete In Triplicate) <br /> Application is hereby made to the Saxe 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 t <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District.. <br /> JOS ADDRESS/LOCATION �O 6 /�G"��-j` ��p" CENSUS TRACT <br /> Owner's Name r �T­ <br /> Phone <br /> Address K . czee-7c�w 7� City <br /> Contractor's Name / �`f!fi�S -L�_� _ cense ���2a.cs74 Phone ' <br /> TYPE OF WORK (Check): NEW WELL ^ DEEPEN / / RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION / PUMP REPAIR/ / PUMP REPLACEMENT -7 <br /> PUMP a ; <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LIN RIVATE DOMESTIC WELL e90' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS • <br /> Industrial Cable Tool. Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing Q <br /> Domestic/public Driven Gauge of Casing <br /> t Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout �_�� <br /> .Disposal Other Other Information ' <br /> _Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor 47-5 <br /> Type of Pump_ H.P. <br /> PUMP REPLACEMENT: . j_-j -State Work Dane <br /> PUMP..REPAIR:_ ,Y -. .:W :� /_ State_ Work, Done-: _ - - <br /> two- <br /> DES-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 a <br /> WELL DRILLERS REPORT he well and notify them before putting the well in use. The above <br /> information is tr to the best of my knowledge and belief. 1 WILL CALL FOP, A GROUT INSPECTION , <br /> PRIOR TO GROU 0 <br /> SIGNED TITLE <br /> ;110RAWPLOT PLAN 'ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS I/F NAI, INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 3/76 2M <br /> 1--74 <br /> E H 1426 Rev. '- <br /> ... <br />