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• � t <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ,,✓1 <br /> OF OFFICE USE: 601 E. Hazelton Ave. , Stockti- n, Calif. <br /> Telephone :, (209) 466=6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, Y� <br /> THIS PERMIT EXPIRES 1 YEAR'.FRO M DATE ISSUED. Date Issued f�✓r�� <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 Joaquii <br /> County Ordinance No. 1862 and the Rules and Regulations of the ,San Joaquin Local Health District.. <br /> JOB ADDRESS/LOCATION ' CENSUS TRACT <br /> i Owner's Name u. 4 PA p I'.C_A,q.__ _ � Phone 3 3' <br /> Address P6 .- o ' 0 . .- F: A City T/-,4c_ - <br /> Contractor's Name d til�Q7�E/C� Pp.,,A _,q, License #32jz Phone G3z�� 3Z <br /> i TYPE OF WORK (Check) : -NEW WELL DEEPEN / _ <br /> AL / RECONDITION /_/ DESTRUCTION / _ <br /> t PUMP INSTALLATION /�_PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / Y _ ----- -- <br /> DISTANCE TO NEAREST: SEPTIC TANK L3S*-SEWER, LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER R <br /> r PROPERTY LINE - PRIVATE DOMESTIC WELL 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 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal 5 D 6]r <br /> Cathodic Protection Rotary Type of Grout DF&re 1211 CE <br /> Disposal Other Other Information <br /> Geophysical 33 Surface Seal Installed By: __ C <br /> PUMP INSTALLATION: .,Vontractor. fA 0 I /, •j,• E, <br /> Type of Pump vr' Li. B /nE� 5,,BA� H.P. <br /> PUMP, REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: 4 / / • State Work Done ` <br /> DESTRUCTION OF WELL: Well Diameter e <f Approximate Depth 7� <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 Sari 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 knowledge and belief. I WILE CALLFOR�A• GROUT INSPECTION <br /> PRIOR TO .GROUTING AND A FINAL INSPECTION. I <br /> k SIGNED T TITLE <br /> t (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR -DEPARTMElgTUSE -ONLY -- - <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE - <br /> ADDITIONAL. COMMENTS: <br /> f PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION. BATE INSPECTION BY DATE <br /> . r <br /> E H 1426 Red - 0 1 2M <br /> , <br />