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YA) SAN JOAQUIN LOCAL HEALTH-DISTRICT <br /> FOF"6*6 FICE USE: — 1•1501 E. Hazelton Ave. ,.,.SCockton, Calif. <br /> Telephone : (209) 456-6781 U <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> L <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued X J d <br /> jy !� (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct <br /> and/or install the work 'herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 186.2 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION q6 U CENSUS TRACT <br /> SQ4LO'sS Rp0S <br /> Owner's Name �S7�G �� GS Phone 063 <br /> n n ' <br /> Address k065- '�C C!L - City <br /> Contractor's Name {' [iu. License Phone L� �b <br /> u <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDATION /_/ - DESTRUCTTON`�/�--�" <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /7 <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 PUBLIC DOMESTIC WELL _ <br /> INTENDED USE sM %TYPE OF WELL CONSTRUCTION SPECIFICATIONS CF*'. <br /> t Industrial Cable Tool Dia. of Well. Excavation <br /> __?::�7WDomestic/private I Drilled Dia, of Well Casing �.. <br /> ., ' Domestic./public Driven Gauge of Casing S <br /> Irrigation I� Al 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 V t4 4tAi-4v <br /> TYpe'E of Pump <br /> PUMP REPLACEMENT: % / II State Work Done <br /> PUMP_.REPAIR: / / ,, state State Work Dane <br />� DES <br /> JRUCTION OF WELL: Well' Diameter _ Approximate Depth <br /> i 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 completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT ofsthee well and notify them before putting thewell 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 GR TING APA' IN'AL INSPECTION. <br /> SIGNED ' 3; s' ., TITLR <br /> J Q(DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PiIASE I <br /> `� <br /> '"` + BATE <br /> APPLICATION ACCEPTEif!•BY4„. ��.. <br /> ADDITIONAL COMMENTS = <br /> PHASE II aRnf TNRPELQrION PHASE III/FTNAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE CD <br />