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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR;OFFICE USE: I1601 E. Hazelton Ave, Sto <br /> ckton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. >O_a4l6 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -/L <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 Joaquin <br /> County Ordinance No.- 1:862 and the Ru and Regulations of the San.Joaquin.Local Health District., <br /> JOB ADDRESS/ <br /> AT <br /> CENSUS TRACT <br /> .Owner's Name7 <br /> Phone. <br /> Address . City " <br /> Contractor's Name License #/y ,(,,4Pfione 7 .,% <br /> TYPE Ole WORK (Check): NEW WELL / DEEPEN /7 RECONDITION /7 DESTRUCTION Fi <br /> PUMP INS.TALLATION '/ / PUMP REPAIR/PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST`.. SEPTIC TANK SEWER LINES PIT PRIVY P <br /> SEWAGE' DIS 5AL 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 <br /> domestic/private Drilled Dia. of Well Casing <br /> Domestic/public-. Driven. Gauge of Casing <br /> Irrigation f <br /> g Gravel Pack Depth of Grout Sea3. � <br /> Cathodic Protection _1, Ratary. 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: <br /> .State Work Done <br /> QESgTRUCTION OF. WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with alllaws and regulations of the San Joaquin Local Health District <br /> and the State of Californi:a: pertaining to or regulating well •'construction:.. Within FIFTEEN DAYS <br /> after completion of my.: work on4a 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 GROUTIN AND A• FINAL IN PECT.ION. <br /> SIGNS TITLE <br /> {DRAW PLOT PLAN ON REVERSE SIDE _ T' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> AP- PLICATION ACCEPTED BY: DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE 141 FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DljT _ <br /> E H 1426 . 1_0 .�_ <br />