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SAN JOAQUIN LOCAL HEALTH DISTRICT � <br /> FOE OFFICE USE: V�Z1601 E. Hazelton Ave. ,'Stodk.ton, Calif. G ev /v7t <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �-6 a/�J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _ 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 No. 1862 and the Rules and Regulations of the San Joaquin Local. Health District. <br /> JOB ADDRESS/LOCATION �TI-- -I-41d1&A,P4U CENSUS TRACT <br /> Owner's Name <br /> VA,'i2f4. �L e <br /> Address 1-291 City CFAdl&/zx � <br /> Contractor's Name ' License # ��Phone 5;72-AMI <br /> ac''S`C10 Cts i <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/—/ RECONDITION /_% DESTRUCTION /-7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/% PUMP REPLACEMENT /—T <br /> Other / J <br /> DISTANCE TO NEAREST: SEPTIC TANK IQ SEWER LINES PIT PRIVY Ofd u - y <br /> SEWAGE DISPOSAL FIELD ' -t- CESSPOOL/SEEPAGE PIT OTHER �y <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 / I <br /> v Domestic/private Drilled Dia. of Well Casing �j,dL <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal 0 . <br /> Cathodic Protection Rotary Type of Grout <br /> DisposalOther Other Information <br /> GeophysicalSurface Seal Installed B : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: J / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> 6 _ _ � Describe Mater 1 and Procedure s <br /> I a ree t <br /> y g o comply with all laws and regulations o the San Joa in Local HeWlth District <br /> and the State of California pertaining to or regulating well'canstruction. 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 G INSPECTION <br /> PRIOR TO G OUTING AND-,A FPNAL IN ECTION. <br /> SIGNED 11 iCITLE ' <br /> D_2gLOT PLAN ON RE E SIDE " ' °• <br /> FO DEPARTMENT US ONLY Jkl <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> P E I G OUT INSPECTI N PHASEI I/ INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DA <br /> E H 1426 Rev. 1-74 +.i. 3/76 2M <br />