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I �/D SAN JOAQUIN LOCAL"HEALTH DISTRICT - <br /> FOF:rOFFICE USE: 1601 E. Hazelton Avc. , -Stdckton, Calif. <br /> Telephone: (209) 466.--67$1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES. 1 YEAR. FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Applidation 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. 1852 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> X o AI CENSUS TRACT <br /> Owner's Name n7 4,CS, DV zz <br /> Phone � ' <br /> op <br /> Address <br /> city <br /> Contractor's Name . �, Sdam, '0t <br /> License 010 Phone 833 o,7 <br /> TYPE OF WORK (Check)., ' NEW WELL '/�.r DEEPEN /7 RECONDITION /7 DESTRUCTION4 <br /> PUMP,INSTALLATION / / PUMP REPAIR 2V PUMP REPLACEM Iff— f T <br /> Other, / / <br /> DISTANCE TO NEAREST: SEPTIC TANK ' <br /> SEWER LINES. . PIT PRIVY Cil . <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE -PIT Ogg nb ' <br /> PROPERTY LINE - PRIVATE- DOMESTIC WELL PUBLIC DOMESTIC'WELL�� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS r <br /> Industrial Cable Tool Dia. +of Well Excavation <br /> Domestic/private Drilled Dia. .of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal + <br /> Cathodic Protection Rotary Type of Grout E <br /> Disposal � Other Other Information <br /> Geophysical Surface Seal Installed By: ; <br /> M <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump I <br /> H.P. <br /> PUMP REPLACEMEI'1T: E7 State Work Done <br />'P1"P REPAIR:" <br /> „��" `5tate-work Done __eR Id ----- <br /> ES•TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO GROU NG AND A NAL INSPECTION. <br /> SIGNED <br /> TITLE <br /> DRAW OT PLAN ON REVERSE SIDE <br /> PHASE I F R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY r <br /> MDATEENTS7f <br /> ADDITIONAL COMr-- <br /> PHASE II T .INSPE ON PHAS IT FINAL INSPECTION <br /> INSPECTION By DATE INSPECTION. By DATE -/1- 7j <br /> E H 1426 Rev. 1-74 <br />