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1 <br /> L <br /> F JOAQUIN LOCAL HEALTH DISTRICT <br /> 6 aC5 OFFICE USE: 1601 i. Hazelton Ave . , ,SCockton, Cal_ . <br /> ' Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUME PERMIT Permit No. i SS/ <br /> �^ THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> ?plication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> ..nd/or install the work herein described. This application is made in compliance with San JoagL <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District <br /> ,�)B ADDRESS/LOCATIONt f__�C3y(Jh L" / /'M C Tl-,I-� CENSUS TRACT <br /> mer's Name ` ��) /� �L / G rr,y/=U Phone <br /> Address0 `/z" L- of M 3 TQ c4� city <br /> 4 <br /> `)ntractor's Name L /�� �.,,, L� License 117L L0Z Phone o-5 <br /> PE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> 4STANCE 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 /> r 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 Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> _ Cathodic Protection Rotary Type of Grout <br /> _Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> MP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> MP REPLACEMENT: / / State Work Done <br /> 'UMPREPAIR: / / State Work Done <br /> `iTRUCTION OF WELL: Well Diameter Approximate Depth <br /> v <br /> Describe Material and Procedure <br /> .hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> nd the State of California pertaining to or regulating well ''construction. Within FIFTEEN DAYS <br /> `ter completion of my work on a new well, I will furnish the San Joaquin Local Health District <br /> LL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> n0formation s true to the best of my 'knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> 2i0R TO G : NG fND A � AL INSPECTION. <br /> ON ED �1— TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) _ <br /> FOR DEPARTMENT USE ONLY <br /> ASE I <br /> .PLICATION ACCEPTED BYDATE <br /> ')DITIONAL CODLMENTS: <br />