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SAN JOAQUIN LOCAL HEALTH DISTRICT !/^J <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , .Stocktori, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 17� <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date`Issued <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 Re ulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION /dry - ,#SUS TRACT <br /> Owner's Name Phone <br /> Address City <br /> .Contractor s Name <br /> � ' ' License f ` Phon <br /> TYPE OF WORK (Check) : NEW WELL/(DEEPEN / / RECONDITIONµ/ / DESTRUCTION / k <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMA REPLACEMENT I-7 <br /> Other / / -- --- <br /> DISTANCE TO NEAREST: SEPTIC TANK Gt SEWER LINES ,s PIT PRIVY <br /> SEWAGE DISP SO AL. FIELD CESSPOOL/SEEPAGE PIT OTHER r <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL, PUBLIC DOMESTIC WELL <br /> j INTENDED USE TYPE OF WELL - � �_Q w'CONSTRUCTION SPECIFICATIONS <br /> Industrial mo ble Tool Dia, of-Well Excavation 4 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing zQ <br /> yam.-Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout f <br />[ Disposal Other Other Information <br /> k Geophysical Surface Seal Installed By: A -Cd 7 l <br /> t PUMP INSTALLATION: Contractor , _ <br /> Type of Pump <br /> PUMi' REPLACEMEN:Z:- S •ate Work none - - — <br /> PUMP °REPAIR: '/ / State Work Done <br /> DES•TRUCTION -)F'WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> -. ,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 GRO ING D A FINAL INSPECT1,9N,7 <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: 14 <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ' <br /> - - <br /> 6/77 - 2M <br />