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CG"` & � SAN JOAQt1IN LOCALIiEALTH DISTRICT <br /> • FOAiOFFICE USE: 1601 E. Hazelton:Ave. ,`Stackton, Calif. <br /> Telephone: ' (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,V_ p y <br /> THIS-PERMIT EXPIRES 1,YEAR FROM DATE ISSUED Date. Issued _.a` <br /> (Compiete,Zn,Tr'iplicate) <br /> Application is hereby made to the San Joaquin local Health District for a permit to construct <br /> i and/or install. the work herein described. -.This .application,.is made in compliance with San.Joaquin <br /> County Ordinance No. 1862 and the Rules :4nnd Regulations of• the San Joaquin Local j1ealth District. <br /> rnc'e- on lxccd- r1e,0 . Cad/ "P � " f✓ 57 3 V �. <br /> JOB ADDRESS LOCATION CENSUS TRACT <br /> Owner°s Name Phone <br /> Address 3 f a - c city , , ,,,.._ + <br /> Contractor's Name `' s7 ce sel ­Phoney.- fi � <br /> w <br /> TYPE OF WORK (Check): NEW WELL / 7 DEEPEN -/-7 RECONDITION- /_7 DESTRUCTION _1 <br /> t PUMP INSTALLATION / / PUMP REPAIR E1 PUMP REPLACEMENT j7 <br /> E Other / / . <br /> DISTANCE TO NEAREST: SEPTIC-TANK SEWER LINES:. PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER e <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF -WELL CONSTRUCTION SPECIFICATIONS. <br /> k Industrial Cable Tool `-Dia. -of Well Excavation <br /> Domestic/private Drilled y..-." ,. Dfai. of•Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> �C 'Irrigation Gravel Pack Depth of. Grout Seal <br /> Cathodic Protection , Rotary Type of Grout <br /> € Disposal. s Other, Other Information <br /> Geophysical -- - `" Surface Seal Installed By:- <br /> PUMP <br /> y _Pi1MP INSTALLATION: Contractor <br /> Type of Pump ape H.P. <br /> PUMP REPLACEMENT: / // State Work Done } :- <br /> PUMP '.REPAIR: /� State Work Done <br /> r + <br /> ,DES TRUCTION OF WELL: Well Diameter Approximate Depth <br /> i Describe Material and Procedure- <br /> . r <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 wellconstructi.on. , Within FIFTEEN DAYS. <br /> 4 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.. jThe above <br /> i information is true to the-best' of my .kno) and`belief'.`-°I WILT; CALL FORA GROUT INSPECTION <br /> PRIOR TOUTING AND A FINAL I P N. <br /> SIGNE ITLE ,.�, <br /> (DRAW PLOT PLAN ON ERS SIDE) >> <br /> . .FOR DEPARTMENT USE ONLY <br /> f PHASE I <br /> ' APPLICATION ACCEPTED BY _.DATE �. Z <br /> � e <br /> ADDITIONAL COMMENTS: Aj <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ;C4 _ DATE p- 7 <br /> 7_ <br /> ki E H 1426 Rev. .1-74ME <br /> 1., <br />