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�vcl� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 0E OFFICE USE: 16(v?. Hazelton Ave. , Stocktorn, Cam <br /> Telephone: (209) 466-6781 _ <br /> i` APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No._;e_:1 V <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued y-//.�6 <br /> (Complete In Triplicate) <br /> )plication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> -id/or install the work herein described. This application is made in compliance with San Joaqu! <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District.b1 <br /> )B ADDRESS/LOCATION j + CENSUS TRACT <br /> ,'*xner's Name fN A�iRL7r "f�"/G 2� G L Ud - Phone <br /> "-dress /G/✓ CitytTi��a� <br /> .ntractor's Name H���✓/%✓GS BieOS DZi�L ✓a �" <br /> License 1129d�/� Phone�`ZZ-�®3/ <br /> -'PE OF WORK (Check) : NEW WELL DEEPEN/% RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR. PUMP REPLACEMENT /_7 <br /> Other <br /> STANCE TO NEAREST: SEPTIC TANK l LI3E5 _ IT PRIVY <br /> SEWAGE DISPOSAL FIELD/M 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 ExcavatioIV <br /> n <br /> Domestic/private Drilled Dia. of Well Casing /3 ii PGR si-G <br /> Domestic/public Driven Gauge of Casing TD P14 G <br /> Irrigation Gravel Pack Depth of Grout Seal SO <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> , (/ 07W't--g':� <br /> 'UMP INSTALLATION: /Contractor <br /> Type of Pump H.P. <br /> vh -26- 7y7 f� <br /> 'UMP REPLACEMENT: / / State Work Done <br /> MP .REPAIR: / / State Work Done f <br /> ^STRUCTION OF WELL: Well Diameter Approximate Depth O f <br /> Describe Material and Proc dure <br /> ,Es�iz�yeo o�z ��� .� <br /> hereby agree to comply with all laws and regulatio s 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 /> BELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> formation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTIO <br /> IOR TO GROUTING• AND A FINAL INSPECTION. <br /> SIGNED P TITLE <br /> (DRAW LOT PL ON REVERSE SI➢ <br /> _ FOR DEPARTMENT USE ONLY <br /> 'HASE I <br /> �DPLICATION ACCEPTED BY A/ DATE <br /> DITIONAL COMMENTS: <br /> ` PHASE II GROUT INSPECTION PHASE I FIN INSPECTION <br /> INSPECTION BY DATE S1- /�-7� INSPECTION BY DATE - /8'7y <br /> E H 1426 Rev. 1-74 � � � � )i/75 PM <br />