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l sa <br />-- SAN JOA UIN LOCAL HE A A�►(- <br /> Q ALTH I � <br /> FOA7OF�ICE USE: 1601 E. Hazelton Ave. Sto Iif. y Z <br /> 9 <br /> Telephone: (209) 466 1 <br /> APPLICATION FOR WELL CONSTRUCTIO POIRP T Hermit No. <br /> IP1 ' 0c <br /> 10 THIS PERMIT EXPIRES 1 YEAR FROM DAMI I5' ?,�cjate Issued <br /> (Complete In Triplicat �A ` <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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION S CENSUS TRACT }/q <br /> Owner P s Name _ 4�, ���O �,,S Phone Z�7 7-,-j- <br /> < ,< <br /> r <br /> Address ,/�C� 3�- 2 & WOODS WELL 1 DRILLING City), ©ej�fC 61101 <br /> , / / 1 Simmerhorn 752'3 7 <br /> Contractort s Name 1�lQf1CL.S ,�// �r� 79 ' �nse # Phone <br /> 1 gF-� SSI�II <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN /7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION 0 PUMP REPAIR /-7 PUMP REPLACEMENT /7 <br /> Other / 7 <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 /> Industrial Cable Tool Dia. of Well Excavation a 1'� <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing jQ <br /> Irrigation Gravel Pack Depth of Grout Seal �— <br /> Cathodic Protection Rotary Type of Grout S .tr �rnNrrJ�" <br /> Disposal Other Other Information mak' <br /> Geophysical Surface Seal Installed BY: lcr6 o d s <br /> PUMP INSTALLATION: Contractor <br /> S <br /> Type of Pump lwt°rs A.P. <br /> PUMP REPLACEMENT: Ll State Work Done <br /> PUMP :REPAIR: /7 State Work Done - <br /> ,RES-TRUCTION 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 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 GROUTING.-AND A FIN INS ECTION. <br /> SIGNED TITLE 4:2 `4 <br /> (DRAW PLOT PLAN ON REVERSE SIDE) - <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 441� DATE Z <br /> ADDITIONAL COMMENTS: <br /> PHASE I ROUT INSPECTION PHAS&.AkI/FINjL INSPECTION <br /> INSPECTION BY /,Z, ATE ✓fid C INSPECTION BY 4yDATE 5' do <br /> 12e 1Y) <br /> 1426 Rev. 1-74 1 1-7412M_ <br />