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'3� \kc_ - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave: ' , <br /> FOF�rOFFICE USE: 5'Eockton Calif. <br /> Telephone: (20.9)"."466-6781 7s`-36/w <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT - Permit No. 7,S_-t(-///o <br /> THIS PERMIT EXPIRES 1-YEAR FROM DATE ISSUED `. "Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Uca1 Health Di tt.;ct .for a permit to construct <br /> and/or install the work herein described. This applcatiori,Fis;�uad . ii� compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and.,:Regulations of_ e :Sa _ oaquin`Local Health District. <br /> JOB ADDRESS/LOCATION I - ` CENSUS,TRAA71 CT,'*-VF <br /> ho <br /> Owners Name <br /> Address 3 f " tiCity-28 -- <br /> Contractor's NameE.� ` T License ��,1 7 Phone , -D C�QG <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN - RECOITION /7 .DESTRUCTION` ` ' s <br /> PUMP INSTM -/_7ND <br /> ATIONPUMP': REPAIR. /�/. PUMP REPLACEMENT. /7 " <br /> Other <br /> '- a I <br /> DISTANCE TO NEAREST: SEPTIC TANK. SEWER,LINES '` PIT PRIVY <br /> SEWAGE DISPOSAL FIELD'--f "? a CESSPOOL./SEEPAGE PITS:. OTHER <br /> PROPERTY LINE - PRIVATE 'DOMESTIC WELL PUBLIC.DOMESTIC,' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION,SPECIFICATIONS? <br /> industrial Cable Tool Dia of Weil Excavation <br /> Domestic/private- Drilled Dia of Well Casig { . <br /> Domestic/public Driven :k Gauge -of Casing <br /> o�-tGIrrigation . � . GravelPackF Dep , <br /> Y. Te f— ; Cathodic Protection �T�.Rotary o :Grout <br /> Disposal ' Other Other Information4 <br /> Geophysical Surface Seal Installed B ., <br /> PUMP INSTALLATION: '� -Contractor <br /> Type of ' iliap <br /> a s n 7 ' <br /> PUMP REPLACEMENT: / / . Stat Work Doric <br /> —PUMP '.REPAIR: Work Done <br /> ESLTRUCTION OF WELL: We11 Diameter Approximate Depth <br /> -. De c ribsr Material-and-Procedtiire,. <br /> $ <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-ito -orregula ing-'pertainingWithin FIFTEEN DAYS <br /> after completion of my work on +a- new well,. I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS"REPORT of the welk and notify them before putting.-the..well in-use. The above <br /> information is true to the,best of my knowledge and belief. I WILL CALL FOR A,GROUT INSPECTION <br /> PRIOR TO GR ING AND A F_ AL- JNPE!GTION. .. - -. .. <br /> SIGNED TITLE —Q�a4 <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT -USE-ONLY <br /> 1 PHASE I - 'a • <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS:_ - <br /> f f PHASE II GROUT INSPECTION PHASE.TTI FINAL INSPECTION <br /> INSPECTION BY DATE ;,° INSPECTION BYO' DATE /l-,QL S <br /> 'i E H 1426 Rev; ;l-7 4 <br /> 1-74 2M <br />