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SAN JOAQUIN LOCAL"HEALTR DISTRICT <br /> FOFS 75PFICE USE: 1601 E. Hazelton -Ave.,.', a'St"ockton, Calif. <br /> Telephone: {209) 4W-6781 <br /> APPLICATION FOR WELL. CONSTRUCTION OR PUMP PERMIT Permit No. Q <br /> .. - --- .. ... .. ,. :�r. •r.r. � P-& �,:��.' !y!'.-C. .r_ �`.. ^ir:,,-. .e...-... .gra+., ., e . . ..,,- t S / ✓ Q/� :. <br /> THIS PERMIT.-.EXPIRES 1 YEAR. FROM,DATE ISSUED N,:r+ Date!Issued 4=7,75 <br /> 53 `f' Triplitate). , 4 .. <br /> Application is hereby made to the San Joaquin;_Local,Meaith Districtfor wpdrmit,to construct <br /> and/or install the..work, herein described. .. This application,.is. madei:in, compliance with San Joaquin <br /> County` Ordinance No 1862;,an the '_Rules ,and,.Regulations:.of,.che San Joaquin Local-Health District. <br /> . . %cAE-S r 4A*,9,5 tcAlrR.5 ,PA Re-6L. At) x: <br /> JOB ADDRESS/LOCATION �' 82�"� ,�: ggv y .AG4Z_1' SUS 1TRA CT 0 05' ;Q-30 <br /> Owner f s Name f ]///1� � D /�� l.�t Phone <br /> Address WAIA <br /> `City <br /> Contractor's Named (r �,Ilwvolo License _LIZ Phone <br /> �.T. <br /> TYPE OF WORK (Check): ' NEW WELL /? DEEPEN, /CONDITION /7 • DESTRUCTION'./_7 <br /> PUMP INSTALLATION / '/ PUMP REPAIR /_7 . PUMP REPLACEMENTI-7 <br /> .E Other / ,/ . d 50Z� A d <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER, LINESik �p PIT PRIVY , <br /> SEWAGE DISPOSAL FIELD, CESSPOOL/SEEPAGE PIT, OTHER ro <br /> y 'PROPERTY LINE - PRIVATE DOMESTIC WELL'' PUBLIC DOMESTIC WELL C, <br /> INTENDED USE TYPE OF WELL, Yt CONSTRUCTION: SPECIFICATIONS <br /> >' Industrialable Tool Dia. 'of Well Excavation <br /> c---'9ome s tic/private Drilled <br /> Dia. of Well Casing <br /> Domestic/public Driven. Gauge of Casing <br /> a Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection- Rotary Type of Grout <br /> Disposal Other Other,.Information <br /> Geophysical Surface Seal. Installed By: <br /> PUMP INSTALLATION: - Contractor <br /> Type :of Pump H.P. pt <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP !REPAIR%;:i, ;_State Work-Done <br /> ,RES;TRUCTION OF WELL: WellADiameter Approximate Depth <br /> Describe Material and Procedure S <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-beet.of%mykknowledge and belief. I' WILL CALL FOR A -GROUT INSPECTION <br /> PRIOR TO GRO I AND A F N ECTION. <br /> SIGNED `; TITLE - <br /> ,.. <br /> (Y)RAW PLOT ..PLAN ON REVERSES E -. ' <br /> FOR DEPARTMENT USE ONLY i <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE it <br /> ADDITIONAL COMMENTS: r <br /> -PHASE II GROUT INSPECTION. PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE ..f INSPECTION BY et:< DATE <br /> . _ -.7 _ <br /> i E H 1.426 Rev. 1-74 <br /> . , 1-74 2M __r <br />