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v Y <br /> SAN JOAQUIN LOCAL�TH DISTRICT <br /> FpL OFFICE USE: 1601 E. Hazelton Ave'. , tockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL.CONSTRUCTION OR PUMP PERMIT Permit No. 5-7zSr4J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Z--ay-2g <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 93I_ - W/7LT�'� L A E. CENSUS TRACT <br /> Agussnecs 4 j.4 _ 37 <br /> Owner's Nam tA y7 KI Phone <br /> Address _ --- :�.3! Gu� G,Te L 4 ti e. City �j�G441d..Z^ <br /> Contractor's Name j < j/—a— /D" *-1^ aj License # Phone ' WZZ-&Aj"0 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN/ / RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTELATION /0r-PUMP REPAIR / / PUMP REPLACEMENT _/ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL IELD -50- * CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE A4RIVATE 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 Driven Gauge of Casing <br /> Irrigation _ Gravel Pack Depth of Grout Seal <br /> Cathodic Protection _ Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor , <br /> Type of Pump w H.P. <br /> PUMP REPLACEMENT: / / State Work Done ` <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION 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 com?LEREPORT <br /> i work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILo the well and otify a before putting the .well in use. The above <br /> informatis true t the-bes of p ed an e I WILL CALL FOR A GROUT INSPECTION.PRIOR TOTI G FIN INSP N11. <br /> SIGNED TITLE <br /> D W PLAN ON RE SE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE\N,0� <br /> ADDITIONAL -COMMEIiTTS: <br /> PHAU JI 23PUT INSPECOO PHAS I I FINAL NSPECTIOJR <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 4 <br /> E H-1426 Rev. 1-74 ( . 76 <br />