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_. . <br /> SAN JOAQ€ IN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: `' 1601 E. Hazelton Ave . , Stocktr_rn, Calif. <br /> Telephone : . .(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> q <br /> ,4-3 <br /> [� THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 J02'14uin <br /> County Ordinance No. 1862 . and the Rules and Regulations of the San Joaquin Local Health District. <br /> .... pal n-7 - 24.3 -�-70 3(� <br /> JOB ADDRESS/LOCATION T - �' ic - �2 CENSUS TRACT a <br /> Owner's Name Phonen���"j`- /h 3 <br /> Address City <br /> Contractor T s Name I/ License # Phone � T—f <br /> i <br /> TYPE OF WORK (Check) : NEW WELL /�K DEEPEN '/—/ RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / — r <br /> DISTANCE TO NEAREST: SEPTIC TANKS SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <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 p <br /> t Domestic/private Drilled Dia. of Well Casing '� <br /> OQY <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 B : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done o <br /> PUMP REPAIR: - JT / / -state Work Done 4 <br /> DESTRUCTION OF WELL: Wel1: Diameter Approximate Depth <br /> Describe Material and Procedure <br /> s <br /> A <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 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 puttingthewell 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 G OUTING FINAL INSPE TION. <br /> SIGNED TITLE _ l" <br /> RAMI PLOT PLAN(/ON REVERSE SIDE} <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I #:R - -- -- <br /> L'iAPPLICATION ACCEPTED BY DATE Y <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTI N i <br /> INSPECTION BY TE `v D-r6INSPECTION BY ATE 7 g <br /> HJT Vk: r�V bei.,., <br /> E H :4 2 6 Rev. , 1�-7 4 � ��1�e_� �.,� � � (��irxav�'`17 _ 2M <br />