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ii <br /> CG /0,le ' SAN JOAQUIN LOCAL HEALTH` DISTRICT <br /> FORrOFFT E USE: 1601 E. Hazelton Ave. , St ckton, Calif. ' <br /> Telephone: (209) 4,�6-6781 <br /> APPLICATION FOR WELL CONSTRUCfI N OR PUMP PERMIT Permit No. 30010 !, <br /> THIS PERMIT EXPIRES. 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) ( k�3--,03ro --0 ' <br /> Application is hereby made to the San Joaquin Lodal Health District for a permit tb construct I <br /> and/or install the_work herein described. This application is made in compliance with San Joaquin, <br /> County Ordinance No. 1862 acid the Rules and Regulations of the Sart Joaquin Local Health District. <br /> .TOB ADDRESS/LOCATION � .� ' A/ :F4 ro.2% L2422k CENSUS TRACT <br /> Owner's Name ! Phone <br /> Address 1;� , <br /> City Sa h o rG, <br /> Contractor's Name ) License # Z2A47A0hone i <br /> t <br /> TYPE OF WORK (Check) : NEW WELL /? DEEPEN''/-7 RECONDITION /? DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR {y PUMP REPLACEMENT <br /> Otheil / / (� <br /> N * <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER to i <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial s Cable Tool Dia. of Well Excavation <br /> Domestic/private _ --t Drilled Dia'. of Well Casing <br /> Domestic/public i Driven Gauge of Casing <br /> Irrigation - i Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contrictor <br /> Type cif PumpH.P. 7� <br />' C - <br /> PUMP REPLACEMENT: _ ' % / ,State. Work Done <br /> s <br /> -74 <br /> PUMP REPAIR: E Rate Work Done ,��j� ,„t }�W w A-4#-( VIC <br /> ES111UCTION 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 of the well and notify them before putting. the. well in use.. The above <br /> information is "true 'to the best my,,, wled and belief. I WILL CALL FOR'A'GROUT INSPECTION <br /> PRIOR TO-GROUTING AND A FINAL INSM <br /> SIGNED _ ITLE <br /> DRAW PLOT PLAN ON ERSE- SIDE) <br /> i � FOR DEPARTMENT USE ONLY <br />� PHASE I - <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: 5 <br /> PHASE II GROUTIINSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY ;DATE INSPECTION BY DATE <br /> • w <br /> '� E H 1426 Rev. 1-74 1-74 2M <br />