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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> t�R OFF?CE USE: �1 1511 E, Hazelton Ave , , Stock on, lif . <br /> r Q' <br /> Telephone : (209) 465--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUtU' PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issr:.ed <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 Joaquit <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin local Health District, <br /> JOB ADDRESS/LOCATION tve.% } cc., j er v,_Nk ,J 4- f�/V IL-041-6c- <br /> S,`a-L-r_0CENSUS TRACT <br /> ------•- <br /> Owner's Name !Phone <br /> Address ! r -! -� City <br /> Contractor's Nam OW 7oa4uln Pump co° <br /> License # i Phone <br /> _. <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN_/_/ RECONDIT°ION DESTR C <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 Taal Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pacts Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other _ Other Information <br /> Geophysical Surface Seal. Installed By- <br /> PUMP <br /> :PUMP INSTALLATION: Contractor <br /> Type of Pump - --- �� -- 14.P. <br /> PUMP REPLACEMENT: <br /> /Mate Work Done ��,�,r,�p� t�f..�� �;�•`�-•�1-� <br /> PUMP .REPAIR: / / State Work Done <br /> )ES-TRUCTION OF WELL: Well Diameter _ Approximate Depth <br /> Describe Material and Procedure <br /> L 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 /> 4ELL 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 knowled and belief. I WILL CALL FOR A GROUT INSPECTION <br /> 'RIOR TO GROUTING D INAL�I SP_ -Sa 1-6dgtgffr q- 0 - <br /> SIGNED TITLE (division or San Joaquin Sulphur Ca i <br /> (D P OT PLAN ON REVERSE SIDE) 1q. Sacramento 5t. � <br /> F DEPARTMENT USE ONLY <br /> PHASE I 1 j <br /> APPLICATION ACCEPTED BY .D DATE ! / <br /> ADDITIONAL COMMENTS: <br /> PHASE II OUT INSPECTION PHAS r1111_/FIA INSPECTION <br /> NSPECTION BY DATE INSPECTION p DATE__ <br /> E H 1426 Rev. • 1-74 �` ��7./ - 2M <br />