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k <� - 1.- <br /> :fi. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, 7S__ eF1 <br /> k <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> if; hereby made to the San Joaquin Local Health District for a permit to construct <br /> -nd/or install the work herein described. Thie application is made in compliance with San Joaqt <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District <br /> OB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> rera Name I ` � - ¢,-� Phone <br /> address _::r City <br /> contractor's Name License �--Phone 704 <br /> F <br /> YPE OF WORK (Check) : NEW WELL,-/-7 DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_7 <br /> I � PUMP INSTALLATION / / PUMP REPAIR -/—/ PUMP REPLACEMENT ; /W <br /> Other <br /> [[STANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ,-- 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 ; t <br /> Domestic/public Driven Gauge of Casing - <br /> Gi' Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection- Rotary Type of Grout r <br /> r Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> �... 4ME INSTALLATION: Contractor <br /> a <br /> Type 'of Pump HI.P. `^��.►-`' <br /> PUMP REPLACEMENT: _ <br /> / State Work Dane <br /> F._MP '.REPAIR: State Work Done <br /> y �- <br /> "S-TRUCTION OF WELL: Well Diameter . Approximate Depth <br /> Describe Material and Procedure <br /> �hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> d the State of California pertaining to or regulating well-construction. Within FIFTEEN DAYS <br /> = ter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> ,SELL DRILLERS REPORT of the well and notify them before putting. the..well. in.use...,. The above <br /> if formation is true to the-best .;v my.. no:wledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> OR TO G OUTING AND A FINAL SPE 0'N.' �w <br /> SIGNED "- .t' '� ti % -'TITLE - <br /> (DRAW PLOT PLAN ON VERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> 'RASE I <br /> iRPLICATION ACCEPTED BY DATE a, is s <br /> ,h )ITIONAL COMMENTS: <br /> Vo <br /> PHASE II GROUT I PECTION PHASE III FINAL INSPECTION <br /> :NSPECTION BY DATE INSPECTION BY T_ DATE - - <br /> E H 1426 Rev. 1-74 5 e: � r f. h7e tea. ! <br /> t - <br />