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' SAN JOAQUIN LOCAL HEALTH DISTRICT or <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , =kockton, Calif. <br /> Telephone : (209) 466-6781 <br /> AP LIGATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. /J <br /> 1 77 a-7 s <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issueda <br /> (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 S;n Joaquin L cal health District. <br /> JOB ADDRESS/LOCATION ,/�� r, &YAr C US TRACT <br /> Owner's Namejw) Phone 692- <br /> Address j <br /> f City . <br /> ol <br /> Contractor's Name Ip I license �� (� <br /> Phone lQf <br /> .. <br /> 71 <br /> TYPE OF WORK (Check) : NEW WELL /Z?/DEEPEN / / RECONDITION /_/ DESTRUCTION' / <br /> { PUMP INSTALLATION I"c' PUMP REPAIR / PUMP REPLACEMENT J� <br /> 0`ther <br /> t <br /> DISTANCE TO NEAREST: SEPTIC TANK 1,W f SEWER LINES <br /> f PIT PRIVY <br /> . SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE �! TYPE OF WELL CONSTRUCTION SPECIFICATIONS \I <br /> !i \1 <br /> Industrial Cable Tool Dia. of well Excavation a <br /> Domestic/private .I` Drilled Dia. of Well Casing <br /> - -�-AL Driven.... - �. _ 'Gauige�off:Casing , <br /> ��a�•s�ta:c/pub-li-c <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal I� Other Other Information 6 <br /> GeophysicalSurface 'Seal Installed B <br /> PUMP INSTALLATION:<' x' contractor <br /> JTYpe;of Pump H.P. <br /> 1PUMP REPLACEMENT: f- / I/ State Work Done M � <br /> € PUMP .REPAIR: ' :` ,, I/E / .,State-Work-Done <br /> .': ,-�,�.,�•. . : � w'� , Approximate Depth <br /> DESTRUCTION OF WELL Well Diameter <br /> i D s rCbe Material and Procedure <br /> I hereby agree to comply with a la*s d regulations o the an oaquin Lo al Health District <br /> and.,the °State",of California4ertaining to or regulating well"construction. Within FIFTEEN DAYS <br /> after"campletion f m o k"'on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of1the well and notify them before putting thewell in use. The above <br /> information is true tot <br /> he best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECT ,ON <br /> PRIOR TO G UTING AN NAL IN EGTION.. <br /> SIGNED ITLE <br /> I t (DRAW PLOT L ON REV E SIDE) <br /> R DEP TMENT USE ONLY <br /> PHASE I <br /> $ APPLICATION ACCEPTED Bi DATE <br /> ADDITIONAL COMMENTS: �f <br /> P IIOUT INSPECTION PAjXj _,1:1IjNA� INSPECTI <br /> INSPECTION BY DATE INSPECTION BY DATE. <br /> Iqcen��c <br /> Y 117.7 2M <br /> R H 1426 Rear. 1-74 -- <br />