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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: l/ 1601 ,E. Hazelton Ave. , St-ocktc9 , Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76-.5"11 O%V <br /> 716 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued g Z.0 <br /> 1 (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 No. 1862 and the Rules and Regulations of the San Joaquin Local Health District., <br /> JOB ADDRESS/LOCATION X!5 �� �i�--idiom�� CENSUS TRACT <br /> Owner's Name , !!C -& -d v"l�t4 v - Phone 11 <br /> AddressCity - <br /> Contractor's Name I�G6C1 �c•� License 79r Phone." <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN%/ RECONDITION / / DESTRUCTION /77 <br /> PUMPINSTALLLATION I PUMP REPAIR "/ / PUMP REPLACEMENT /� <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD !1 CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINA PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE :TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 1 Cable Tool Dia. of Well Excavation <br /> k _ � Domestic/private y" i;{ Drilled Dia. of Well Casing �' <br /> Domestic/public Ijl Driven Gauge of Casing ` 71 <br /> Irrigation I Gravel Pack Depth of Grout Seal 5� _ <br /> Cathodic Protection 15— Rotary Type of Grout <br /> Disposal 1 Other Other Information <br /> Surface Seal Installed B : <br /> i Geophysical .. y <br /> PUMP INSTALLATION:._.,,,..Contractor " .a: ccG A- - - <br /> Type of Pump '"' H.P. <br /> PUMP REPLACEMENT: . / / iState Work Done <br /> PUMP REPAIR: / / '.State Work Done <br /> DESTRUCTION OF WELL: Weli Diameter Approximate Depth <br /> Describe Material and Procedure <br /> X hereby agree to comply with all Laws and regulations of the San Joaquin Local Health District <br /> and the State of Californiapertaining to or regulating well,'construction. Within FIFTEEN DAYS <br /> f after completion of my work on a new well, I will furnish the San Joaquin Focal Health District a <br /> WELL DRILLERS REPORT hejwell and notify them before putting the well in use. The above <br /> information is t to the1best of my knowledge and belief. I WILL CALL OR A GROUT INSPECTION <br /> PRIOR TO GROU N S IO <br /> SIGNED TITLE <br /> i DRAW" PLOT PLAN ON RE ERSE SIDE) 1! <br /> FOR EPARTMENT USE ONLY <br /> PHASE I7 Z <br /> APPLICATION ACCEPTED BY i DATE _T/9' <br /> ADDITIONAL COMMENTS: <br /> PHASE II AROUT INSPECtION PHA I /F NAL INSPECTIO <br /> INSPECTION BY" i DATE ! 17 1� INSPECTION BY DATE YOIIS17C <br /> 17 <br /> 3/76 2M <br /> E H 1426 Rev. 1--74 <br />