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SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> F�1Fx;,OFFICE USE: 1601 E. Hazelton Ave. , Stocktoni, Calif-* <br /> Telephone: (209) 466--67.81 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 37 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1-19-7,7 <br /> (Complete In Triplic <br /> Application 'is hereby rude to thate) <br /> e Saga Joaquin Local Health District for a permit to construct <br /> ECounty Ordinance Na. 1852 and the R <br /> and/or install the work herein described. This application is made in compliance with San Joaquit <br /> les and Regulat s of the San -Joaquin Local Health District. <br />! JOB ADDRESS/LOCAT <br /> CENSUS TRACT <br /> ' Owner's Name <br /> 1 Phone <br />! Address <br /> City ' <br /> Contractor's Name <br /> f License � y7� �' - <br /> Phon <br /> TYPE OF WORK (Check): NEW WELL '/? DEEPEN / RECONDITION / DESTRUCTION v/f <br /> PUMP INSTALLATION / / PUMP REPAIR/_7 PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK _ <br /> SEWER LINES - PIT <br /> SEWAGE DISPOSAL FIELD _ CESSPOOL/SEEPAGE PIT <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL:— ,PUBLIC DOMESTIC WELL <br /> INTENDED .USE <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS lV <br /> Industria] _ Cable Tool Dia.--bf Well Excavation <br /> Domestic/private � <br /> Domestic/public. Drilled Dia.1of Well Casing <br /> Driven . <br /> Irrigation Gauge of Casing <br /> __ Gravel Pack Depth of Grout Seal <br /> Cathodic Protection •Rotary Type of Grout <br /> Disposal - Other Other Information ' . <br /> Geophysical Surface Seal Installed "B e <br /> PUMP INSTALLATIONo Contractor ` <br /> Type of Pump ; <br /> H.P. <br /> PUMP REPLACEMENT:.j State Wo Done <br /> PUMP'REPAIR: State Work Done ' ` <br /> t <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> C - <br /> I hereby agree to comply with ail I laws and regulations of the San Joaquin Local Health District i <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 <br /> WELL , I will furnish the San Joaquin Local Health District a <br /> DRILLERS REPORT of the well aitd notify them before putting. tbe..well. in use.... .The ..above <br /> information is true to the"besti "af.m .. � <br /> y knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br />?RINE TO GR UTING AND <br /> SIGNED A FINAL INSPECTION. <br /> N I .. <br /> ' TITLES <br /> z (DRAW PLOT PLAN ON REVERSE SID ". <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> AI'PLICATTON ACCEPTED• BY <br /> ADDITIONAL COMMENTS: DATg <br /> PHASE TI GROUT INSPECTION .• <br /> INSPECTION BY DATE SE I FINAL INSPECTION <br /> INSPECTION BY DATE - <br /> E H 1426 Rev. 1--74ri=- <br />