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SAN JOAQUIN LOCAL HEALTH DISTRICT . ` <br /> FOR OFFICE USE: 1601. E. Hazelton Ave: , Stocktc :., Calif. � <br /> Telephones (209) 466-6781 <br /> AAPICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR Fr OM DATE ISSUED ' Date Issued <br /> (Complete In Triplicate:) 1 <br /> Application is hereby made -to the' San Joaquin Local Health District for a'permit to construct <br /> i. <br /> and/or install the work herein described. This application is made incompliance with Sari Joaquin <br /> County Ordinance No. 1862 and the -Rules and Regulations of the San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION CENSUS TRACT S''' o- <br /> i <br /> Y <br /> Phone � <br /> Owner's Name -3 ._ r <br /> it <br /> Address , . . City _ <br /> Contractor's Named�c — License #/ Phone j <br /> -i <br /> 4 TYPE OF WORK (Check) : NEW WELL `�/ DEEPEN '.I T- .RECONI?T.ITON I DESTRUCTION /_7 <br /> ' <br /> PUMP INSTALLATION El PUMP REPAIR-,& 7 PUMP REPLACEMENT / <br /> Other I I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ PIT PRIVY I <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavationes ', <br /> �� - Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> ii Other _ Rotary / Type of Grout <br /> I' -Other Other Information <br /> PUMP' INSTALLATION: Contractor � <br /> Type of Pump H.P. .3 <br /> PUMP REPLACEMENT: / / State Work.Done <br /> PUMP REPAIR: State Wark Done <br /> ESTRUCTION OF WELL: Well Diameter Ap roximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San' <br /> and <br /> 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 /> t 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. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> ' PHAS II IN EC ON � PHASE IZZ FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 77' <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL ,INSPECTION. � � ' <br /> 4172 <br /> E H 1426 <br />