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G SAN JOAQUIN-LOCAL-HEALTH DISTRICT - - -- l <br /> FOB:(OFFICE USE: 1601 E. Hazelton Ave. , :S tbckton-, 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 <br /> (Complete In Triplicate), <br /> Application is hereby mace to the Sat: 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 /> 30B ADDRESS/LOCATION ..J����ti�_ .�s f� ��s/" .la� . _ - CENSUS TRACT <br /> Owner Q s Name � Qhs ��1� 7�/�41b Phone 16 z 931x6 <br /> Address-- 1202 X1 1. I/&Y �$ ^_. _ �.� . �. ..--- City A v gf Lo 6)ecl <br /> Contractor's Name lAlloC& LicensePhone <br /> TYPE OF WORK (Check): NEW WELL 2/s, DEEPEN %7 RECONDITION /? DESTRUCTION f <br /> PUMP INSTALLATION /7 PUMP REPAIR / / PUMP REPLACEMENT f7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 190 SEWER LINES,/eO LINES,/ PIT PRIVY/Ofd � <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 Cagle 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 (50 <br /> Cathodic Protection Rotary Type of Grout LawcZy- <br /> Disposal _ Other Other Information ^� <br /> Geophysical Surface Seal Installed By: - - - <br /> PUMP INSTALLATION: ContractorN/6\,Y/Y _ - <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 1EPAIR:_ 7 State Work Done <br /> ZES•TRUCTION OF WELL: Well Diameter Approximate Depth N <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-beat of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING ANp A .FINAL INSPECTION. <br /> SIGNED711 <br /> TITLE <br /> 773 t, (DRAW PLOT PLAN ON REVERSE SIDEFOR YEPARTMENT USE ONLY <br /> PHASE I ;i I Li` ?j. +. . <br /> Y <br /> I APPLICATION ACCEPTED BY DATE <br />' ADDITIONAL COMMENTS: <br /> PHASE II GR diMNSPECTION PHASE III/FINAY,. INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 1 T <br /> lE H 1426 Rev. 1-74 1-74 2M <br />