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SAN JOA UIN LOCAL -HEALTH DISTRICT <br /> SOH OFFICE USE: 1601 E. Hazelton Ave. ,' Stbckton, Calif. <br /> Telephone: (209) 466=6781. <br />+ APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT. EXPIRES 1 YEAR FROM DATE ISSUED Date Issued=ate <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 to 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 CENSUS TRACT <br /> Owner's Name 'a PhoneY_ 2y �,�U, <br /> r . <br /> Address City' <br /> Contractor's Name / - License ��, "r Phoney <br /> TYPE OF WORK (Check) :. _. W�WELL-..// DEEPEN. L/_RECONDITION::_I--.DEST.RUCTION-/ —;--- - <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <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 TYPE OF WELL CONSTRUCTION SPECIFICATIONS .� <br /> t Industrial >. Cable Tool Dia, of Well Excavation L- <br /> Domestic/private Drilled Dia. of Well Casing 10 <br /> Domestic/public Driven Gauge of Casing /0 <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 H,P. ' <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done _ <br /> DESTRUCTIONuOF _WELL: Well Diameter Approximate 'Dept -�^ <br /> w, 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 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 GROU G AND A FIN4LIINSPECTIN, <br /> - SIGNED i TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY -7 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 477 t 7 7 2M <br /> E H 1426 Rev. . 1-74 1111477 <br />