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33 f-i q <br /> SAN JOAQUIN LOCAL HEALTH kDIS RIOT . <br /> 1601 E. Hazelton Ave- , 5 <br /> F;OFFS CE US Telephone: (209) 466-6781 7.7- 99 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date .Issued '7-LP <br /> (Complete in Triplicate)srict for a permit <br /> Di <br /> Application <br /> is hereby made to the San Joaquin Loc81 Health istmade in Compliance twith San Joaquin <br /> and/or install the work herein described. This applic <br /> e No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> County Ordinance CENSUS TRACT <br /> JOB ADDRESS/LOCATION Phone <br /> a <br /> Owner's Name City <br /> Address L�L�1� Phone �`3��`� <br /> License # <br /> Contractor's Name <br /> oN f7 <br /> WORK Check): NEW WELL / DEEPEN /=T RECONDITRIO�/PUMPEREPLACIEMEN �I (� <br /> TYPE OF ( p� INSTALLATION PUMP REP / <br /> Other / 7 <br /> PIT PRIVY <br /> _ SEWER LINES — OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK _ CESSPOOL/SEEPAGE PIT — - <br /> SEWAGE DISPOSAL FIELD PUBLIC DOMESTIC WELL 4 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL INSTRUCTION SPECIE TIONS (\ <br /> INTENDED USE TYPE OF WELL }�+ <br /> ---�--C-able Tool Dia. of Well Excavation <br /> Industrial --�-- Drilled Dia. of Well Casing <br /> Domestic/private Gauge of Casing --- <br /> Domestic/public Driven <br /> Gravel Pack Depth of Grout Seal <br /> Irrigation — Rotary Type of Gthut <br /> Cathodic Protection Other �,_ Other Information <br /> Disposal Surf ace Seal Installed B <br /> _Geophysical <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: j//- State Work Done <br /> PUMP '.REPAIR: /� State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> in Loagree lat . Within FIFTEEN DAYS <br /> to comply with all laws and regulations of the San Joaqucal ealth District <br /> Ha <br /> I hereby g pertaining to or reguing well construction <br /> and the State of California p I will furnish the San Joaquin Local Health District <br /> after completion of my work on a new well, putting the..well in use.. The above <br /> WELL DRILLERS REPORT of the well and notify them before p <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOG OUTING AN A FINAL INSPECTION. TITLE <br /> SIGN _ <br /> EDDRAW PLOT PLAN ON REVERSE SIDE <br /> 11 FOR DEPARTMENT USE ONLY <br /> PHASE I _f DATE <br /> ZLI;Izl� <br /> APPLICATION ACCEPTED B <br /> ADDITIONAL COMMENTS: PHASE I I FIN INSPECTION <br /> ATE CTION <br /> PHASE II GROUT INSPECTION INSPECTION BY <br /> INSPECTION BY DATE <br /> v v-, - \Z \7C1 �.J ,�i n 5 1-74 2M �f <br /> f 147, <br /> 1 E H 1426 Rev. 1-74 <br />