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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR-OFFICE USE• 1601 E. Hazelton Ave.:,. Stoe_ktbn, Calif. <br /> Telephone: (209) 466-6781; . <br /> APP CATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZZ=2;p a <br /> THIS PERMIT EXPIRES 1 -YEAR PROM DATE ISSUED Rate Issued <br /> 7 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance .Ido. 1862 ani the Rules and Re ul ions .of -the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Ito 4 esltkl CENSUS TRACT <br /> Owner Q s Name �[�e h �p � ���n P�D v t . Phone <br /> Address / tt 11 City R; r <br /> Contractor's Name },4-S Fie Ifip ; �u License # Phone s,4, <br /> TYPE OF WORK (Check) : NEW WELL /? - DEEPEN '/-7 RECONDITION /_7 DESTRUCTION 1-7 <br /> PUMP INSTALLATION /X/ PUMP REPAIR / / PUMP REPLACEMENT /f" <br /> Otherp// <br /> DISTANCE 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 <br /> Domestic/public , �. Driver: -Gauge-1of�Cas ng-wo�- <br /> X Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 1 Rotary Type of Grout �\ <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By <br /> PUMP INSTALLATION: Contractor 04c 1, d , <br /> Type of Pump nN, rs H.P. <br /> REPLACEMENT:PLACEMENT: <br />�f . . f / State Work Done <br /> 4 PUMP REPAIR: <br /> _ / / State Work Done _ <br /> ES RUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <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-best of my knowledge and belief, I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL' INSPECTION. <br /> SIGNED TITLE X <br /> (DRAW PLOT PLAN ON REVERSE SIDE)` - - <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> . <br /> APPLICATION ACCEPTED BY - DATE <br /> ADDITIONAL COMMENTS: i - <br /> PHASE I-L GROUT INSPECTION PHAS5,,=/X1NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> �� E H 1426 Rev. 1-74 � 1-74 2M <br />