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Cn /a SAN JOAQUIN LOCAL .HEALTH DISTRICT <br /> FORMFi E USE: 1601 E. Hazelton-Ave. , ' Stiackton, Calif. <br /> Telephone: Vw(Z09), 466--6781 <br /> a APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 <br /> THIS PERMIT EXPIRES •1- YEAR• FROM DATE ISSUED Date Issued �2/ <br /> t,„ (Complete.-.In-Triplicate) <br /> Application is hereby made•,to the San Joaquin Local-Ilealth District for a permit to construct <br /> and/or install the work herein described. This applicati.on,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 /> T 11, <br /> JOB ADDRESS/LOCATION. e.y 19 1'tawrZ -L 91f _ &&� CENSUS TRACT <br /> fotlj�2 /L <br /> Owner r s Name _1 C�'�It � .- _ Phone <br /> Address _ �.�S��! T»=�cc ✓i`1 .. .: ,y , .,,,,,._..... City dVto" <br /> Contractor's Name License # /�A--hone z 24 <br /> j TYPE OF WORK (Check) : NEW WELL/-7 DEEPEN /7 RECONDITION /rT DESTRUCTION ( T <br /> PUMP _INSTALLATION / / PUMP REPAIR T' <br /> PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES ' PIT PRIVY <br /> SEWAGE DISPOSAL FIELD _r CESSPOOL/SEEPAGE PIT OTHER <br /> t `'i• - <br /> 'PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL V <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �Y <br /> _ Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled. Dia. of Well Casing <br /> Domestic/public' Driven Gauge of Casing <br /> Irrigation Gravel Pack FDepth of Grout Seal <br /> Cathodic Protection A Rotary Type of Grout <br /> Disposal T K Other _Other Information { <br /> Geophysical = -t Surface Seal Installed By: , <br /> PUMP INSTALLATION: Contractor <br /> yie of :PumpH.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMPI.REPAIR: —1- l-� State Work Done Qir cx <br /> # . aS1RUCTION 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 of}my kno ledge R d belief. I WILL CALL FOA GROUT INSPECTION <br /> PRIOR TO OU ING AN INAL CT N. <br /> SIGNED . ._ � ITLE <br /> D W T PLAN ON MERSE SIDE <br /> s FOR DEPARTMENT USE ONLY <br /> '.PHASE I 7 <br /> j -,APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY-=.-A/4- DATE <br /> + „E H 1426 Rev. 1-74 <br /> 1-74 2M <br />