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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: ;1601 E. Hazelton Ave.,_SZockton, Calif. <br /> Telephone: (209) 466-6781 r <br /> Lk PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77- 9skJ ' <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 construfty-- <br /> and/or install the work -herein- described. This application is made in compliance with San Joaquin I, <br /> County Ordinance No. 1862 and the ule and Regulations of the San Joaquin Local Health• DDistrict. <br /> d .CENSUS TRACT <br /> JOB ADDRESS/LOCATION C <br /> t � � <br /> Owner s Name Phone <br /> Addressci R City <br /> ` icense # 3Phone j <br /> Contractor s Name , <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /_/ DESTRUCTION /_7 A. <br /> PUMP INSTALLATION/ / PUMP REPAIR I / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 95'&e+ SEWER 'LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD Q CESSPOOLISEEPAGE PIT . OTHER"A54-/26R <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC W ` II <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 44VOU <br /> Industrial Cable Tool Dia. of Well Excavation <br /> ` ✓ Domestic/private j, Drilled Dia. of Well Casing <br /> :•Driven-:-- " w Gauge—off Gasing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection,,, 1/ Rotary Type of Grout v <br /> Disposal Other Other Information V <br /> Geophysical Surface Seal Installe�By.:�.�_/IA <br /> V <br /> PUTT, INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> P4 <br /> :PUMP REPLACEMENT: . / / State Work Done <br /> PUMP .REPAIR:" State Work Done "17 <br /> - <br /> ,�y Approximate Depth <br /> . <br />�DESTRUCTTON OF WELL: Well Dia�t'er _,_ ._��.,��-,�-".-�.- "._,,.r .�� � � PP P <br /> a <br /> Describe trial and Proce r'C �- <br /> I" <br /> by -agree -comply'-w th-al-al �r ulations�of,,,the�.S, n�,7oaquin° 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. 1 WILL CALL FOR A GROUT INSPECTION k. <br /> PRIOR TO G OUTING AND FINAL jVSPECTI0N. <br /> SIGNED TITLE <br /> D W PL' PLAN 'ON RE RSE•SIDE <br /> FPR DEPARTMENT USE ONLY <br /> ,PHASE I _ <br /> APPLICATION ACCEPTED BY �'=!` DATE <br /> r. <br /> ADDITIONAL COMMENTS: <br /> PHA E II ROUT INSPECTIOR PHAU IIIAnNAIANSPECTIOK <br /> INSPECTION Be DATE INSPECTION BY DATE 1p <br /> ` 3%76 2M <br /> E H 1426 Rev. 1-74i}o// im­ ,(� <br />