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i <br /> �q SAN JOAQUIN LOCAL"HEALTH DISTRICT <br /> i� FOE;OFFICE USE: -1601 E. Hazelton Ave. , ,Stock6 <br /> ton, Calif. <br /> Telephone: <br /> APPLICATIONpFORONOR1PUMP PERMIT Pe <br /> WELL CONSTRUCTION_ ._ reit N.. 2 <br /> ° THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,�� <br /> (Complete In Triplicate) <br /> Application is hereby made tAo 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. ,3862.and the Rules and Regulations of the San Joaquin Local Health District. <br /> i <br /> JOB ADDRESS/i3OCATION. _ CENSUS TRACT <br /> Owner's Name Phone <br />` <br /> Address Q �`” •- � .. �. :;�= _ 1 .. City <br /> _. <br /> Contractor's <br /> Name <br /> License # ,�'� � Phone J <br /> f . <br /> TYPE OF-WORK'(check) NEW WELL /7 DEEPEN /� PRECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / /T PUMP REPLACEMENT �f <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC .WELL . i PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industriali Cable Tool Dia: of Well Excavation <br /> Domestic/private i Drilled Dia.-of Well Casing' <br /> Domestic/public I Driven Gauge of Casing . <br /> Irrigation i Gravel Pack Depfh of Grout Seal <br /> Cathodic Protection j Rotary Type of Grout' <br /> Disposal ! Other Other Information <br /> -Geophysical. �. - <br /> - ,i �s +s , ._ Surface .Seal, Installed Bv: <br /> PUMP INSTALLATION: ~+ ContractorF. I <br /> Type of 1pump € r I .P. <br /> PUMP REPLACEMENT: / / -State Work Done <br /> Ta . <br /> PUMP :REPAIR: /-7 State Work Done `� ,h <br /> E&TRUCTION OF WELL: Well Diameter, Approximate Depth <br /> Describe=Mat erial--and-Procedure t <br /> I hereby agree to comply with all laws and regulations of the 'San Joaghin' Local Health District <br /> and the State of California pertaining to or regulat.ig well construction. Within FIFTEEN' DAYS <br /> after completion of my work onla 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 GROUT INSPECTION <br /> " PRIOR TO OUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> =� (DRAW PLOT PLAN ON REVERSE SIDE _ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY - 9 7 0 DATE r� •,`� -S_ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASL'IIT FIN INSPECTION <br /> INSPECTION BY DATE 'INSPECTION BY DATE Z <br /> ~E H 1426 ...Rev. �1-74 � ., ,. . �. _ .,.. .,_... ...... . . . ... .. f� <br /> 1-74.2M <br />