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SAN JOAQUIN LOCAL-.HEALTH DISTRICT <br /> nOtOFFICE USE: 1601 E. Hazel tow Ave Calif. <br /> Telephone: -(209,).i.,466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. A/- <br /> THIS,,PERMIT EXPIRES L YEAR-FROM,;DATE',.ISSUED <br /> ' (Complete In Triplicate) <br /> Appliddti6n is hereby made to the San Joaquin- 4ocal-,Uealth District,--fot_ a-permit" to,".-cohstruct <br /> and/or install the work. herein..described,_ This, application:is,,made>-1n. compliance,4ith .'San Joaquin <br /> 7 <br /> County, Ojainan <br /> Co. No_,1862 and the Rule's,,and,.Regu -the-San,Joa, i L ca:11idl-th' Districp'!i,_ <br /> tiona-W. qu n,­_ 'o <br /> JO41ADD:RES$/LOCATI0N 4 ZEBTSU9"'TRACT <br /> Owherts P <br /> Name Phone -Q- <br /> Address <br /> Contractor's Name <br /> License.- Phone d 76 ,M <br /> TYPE. OF WORK (Check):: NEW.WELL L7 DEEPEN /.7- -: RECONDITION, /-7- DESTRUCTION f.7... ... <br /> PDW. INSTALLATION Z:/--PUIMP ,REPAI'R /-7 PUMP REPLACEMENT T- 1_7_ <br /> Other4 d <br /> 4,4,,�42 01 ,11L QW&SaLIZ <br /> U <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESiIC­WEL' L - PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL, <br /> I ' 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 <br /> Cathodic Protection Rotary Type ,of 'Grout' <br /> Disposal Other Other Information <br /> Geophysical. Surface. Seal Installedly. <br /> PUMP INSTALLATION: Contractor <br /> Type 6i' PUMP H.P. <br /> PUMP REPLACEMENT: State--Woik Done <br /> PUMP .REPAIR:. -/7--State-Vork Done, <br /> MS�TRUCT_ION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to 'comply with ell laws and regulations of theSan Joaquin Local Health District <br /> andthe 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:knowledge and belief., I WILL CALL' FOR A'GROUT­IASftCTi6N <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED Wl' :uayv� TITLE <br /> IQ PLOT PLAN ON REVERSE SIDET <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> DATE VIq1,14 <br /> ADDITIONAL COMMENTS: <br /> PHASE I PECTjQN <br /> PHASE III/ I INSPECTION <br /> INSPECTION migo el =m DATE INSPECTION'BY DATE <br /> Z <br /> R H 1426 Rev. 1-74- <br />