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SAN JOAQUIN LOCAL HEAL DISTRICT <br /> FOR OFFICE USE: 1601 E: Hazelton Ave. , St ckton, Calif. <br /> j Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, ,,7f J 6 Sd <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <br /> I , (Complete In Triplicate) <br /> Application is hereby made to the San 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 <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION � ase CENSUS TRACT <br /> Owner's Name C�__U Zl 10,ivGr Phone <br /> Address 0 � City <br /> Contractor's Name —t L1-4. 9 License ��� -QtL Phone 7 <br /> e Z <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN/ / RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other .i/ / <br /> DISTANCE TO NEAREST: SEPTIC (TANK LQ p SEWER LINES 0 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 1(20_ CESSPOOL/SEEPAGE PIT OTHER'S <br /> PROPERTY LINE- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFIC TIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> __ X Domestic/private A Drilled Dia, of Well Casing <br /> Domestic/public ° f Driven- Gauge of. Casing p j"t N i <br /> �— Irrigation 1 Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> t <br /> Disposal Other Other Information <br /> Gegphysical r Surface Seal Installed By: <br /> tl <br /> PUMP INSTALLATION: Contractor 's <br /> Type of Pump ` , H.P. . ; .. <br /> [ t <br /> PUMP REPLACEMENT: . /:''/ : State Work Dane <br /> PUMP .REPAIR: / / State WorklDone <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth -17 <br /> 4 Describe Material and Procedure. ,F <br /> I hereby agree to comply with! all laws and regulations of the San Joaquin Local Health District w <br /> and the State of California pertaining -to or regulating well .cor4truction. Within FIFTEEN"DAYS <br /> after completion of my work on a new well, I will Vurnishi the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the will and notify them before putting the -well in use. The ab vo e--,- <br /> information is true to the-best of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU AND FIN ?ECTION. <br /> SIGNED �` TITLE <br /> D W, =PLAN ON RE ERSE SIDE) <br /> -VOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE -� r <br /> ADDITIONAL COMMENTS: j <br /> PHASE II G OUT INSPECTION PHA <br /> 4 III&WL INSPECTION { <br /> INSPECTION BY ( DATE %7 INSPECTION BY ATE g I <br /> E H 1426 Rev. 1-74 .. <br /> co <br /> 3/7 <br />