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1�0 S&N _JOAQUIN LOCAL HEALTHDISTRICT <br /> LOB!OFFICE USE: 1601 E. Hazelton Ave.°, •Stoektoti;:'Calif. <br /> Telephone; (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR' PUMP! PERMIT Permit No. <br /> THIS PERMIT .EXPIRES:l,,1YEAR FROM DATE,,ISSUED, y rK Date,,Issued-, <br /> - 3 <br /> (Complete- In-Triplicate) <br /> Application is `hereby made to the San Joaquin Local:Health..Dietritt, for a:•permit: tcs.coastxuct <br /> and/or install. the work herein described. This ap,plication. s.; ade> in Lrompliance, with San Joaquin <br /> County Ordinance No. 1862 -and the Rules and Regulations of, the. San3oaqubin Local Health-,Districi. <br /> l7z(QCe.. 95 <br /> °- - � Q+t�; Zvi Zzo a' <br /> JOB ADDRESS/LOCATION A p 1- # /fit ENSUS: TRACT <br /> OwnerQs Name �€ a Phone <br /> Address <br /> .Contractor's.Name a License l . jd-j2111 Phone rM- 7� d <br /> TYPE OF WORK (Check): NEW WELL L47 DEEPEN '/? RECONDITION /7.7 DESTRUCTION. f7 ' <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other /% �f1 r �_ ��L,«r�zs� '� u�}d — A�s <br /> V <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES . PIT PRIVY <br /> ,SEWAGE DISPOSAL FIELDCESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE --•PRIVATE DOMESTIC WELL. - PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS y <br /> Industrial �, Cable Tool Dia. of Well Excavation . <br /> Domestic/private i Drilled Dia, of Well Casing <br /> Domestic/public I Driven . .Gauge. of Casing Az' <br /> _ Irrigation Gravel Pack D'ep' th.,'-of" Grout .Seal <br /> Cathodic Protection 4 Rotary. Type f Grout <br /> Disposal i Other Other Information <br /> Geophysical +Surface Seal Installed By:_ <br /> PUMP INSTALLATION: Contractor <br /> 'A ' Type of Pump } H.P. <br /> PUMP REPLACEMENT: - /7 State Work Done!_ <br /> PUMP'REPAIR: W # /7 -State Work Done <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth _ <br /> 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 notifyithem 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 f <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. +, <br /> SIGNED TITLE. <br /> (DRAW PLOT PLAN ON-REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Cp <br /> APPLICATION ACCEPTED BY C DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE yV-T <br /> t E H 1426 Rev. 1-74 1-74 2M <br />