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�O n SAN JOA,QUIN LOCAL HEALTH DISTRICT <br /> 1/ <br /> FO$rOFFI,CE USE-. 1601 E. Hazelton Ave. , Stackton,'Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,_i -T$- <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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION LY CENSUS TRACT <br /> Owner's Name _EjZp MCIS co <, V e 11ZY9 . _:_ Phone fig-' X558 <br /> Address City za�e440-%) <br /> 1e <br /> Contractor's Name Ad- nJ _ _ License # Phone RSS gp <br /> TYPE OF WORK (Check) :' NEW WELL DEEPEN /_7 RECONDITION /7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR /—/ PUMP REPLACEMENT: <br /> Other <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 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driden Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> r <br /> Cathodic Protection Rotary -' Type-of Grout VIj <br /> Disposal Other Other Information <br /> i <br /> Geophysical Surface Seal Installed By., <br /> PUMP INSTALLATION: -;.Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: WRQ / State Work Done <br />"PUMP"'.REPAIR s L 7 State YWoik Done - I <br /> i <br /> ES-TRUCTTON OF WELL: Well Diameter Approximate Depth i <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. the .well in-use.. The above <br /> information is true to the best of my knowledge and belief.'` TWILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUTING AND AZIN4 INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> ". " . FOR DEPARTMENT USE ONLY <br /> PHASE I _ . <br /> APPLICATION ACCEPTED BY DATE - �S <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASEI F NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - <br /> t E H 1426 Rev. 1-74 M :, 1 <br />