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SAN JOAQUIN LOCAL 11I:A1,T11 D;:<PrICf <br /> FOe, OFF1l.E US': L601 F. Hazelton Ave. , Stockt--r., Cnli" <br /> Telephone: (209) 466-6781 <br /> 3 <br /> j <br /> APPLICATION FOR WELL CQNSTRUC-TION OR fUMl' PL:L"'1T Permit No. 7s� <br /> THIS PERI'TT EXPIRES 1_YEAR FRCM DATE ISSUED Date Issued F .S-2 <br /> (Complete In Triplicate) <br /> iApplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the :Turk herein described. This application is made in compliance vith San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION i- / CENSUS TRACT <br /> Owner's Name Phone ��Se-L),q i <br /> Ad d re s s y �d�do.���.�. l( City <br /> i <br /> Contractor's Name _ License 0 Phone ` <br /> i <br /> TYPE OF WORK (Check): NEW WELL /7DEEPEN /7 RECONDITION /7 DESTRUCTION r7 <br /> PUMP INSTALLATION L� PUMP REPAIR /-] PUMP REPLACEMENT <br /> Other I / <br /> 1 DISTANCE TO NkAREST. SEPTIC TANK SEWER LINES PIT PRIVY <br /> ZFWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER X-, <br /> PROPERTY LINE - PRIVATE DOMESTIC WF,LL —. PUBLIC DOMF.ST-.0 WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation -9 <br /> Domestic/private Drilled Dia, of Well Casing <br /> Demestic/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 /> PUMP INSTALLATION: Conti,,---tor <br /> Type of Pump t H.P. <br /> PUMP RIPLACEMENT: ig State Work Done/` l' r 4 /SJ;77 1441.J"1 <br /> PUMP .tLEPAIR: /-7 State Work Done"' <br /> DES-TRUCTION OF WELL: Well Diameter Approximate Depth <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 regulFting 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 !9 true to the beat of my knowledge anti belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU ING AND FIN I PECTION. <br /> SIGNED -t-, , TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE J <br /> APPLICATION ACCEPTED BY DATE / <br /> ADDITIONAL COHMENTS: _ <br /> PHASE II C.P(Qyj INSPECTION P;iASE III FINAL INSPECTION <br /> INSPECTION BY C DAT.. INSPECTION BY �jam_ <br /> DATE <br /> E H 1426 Rov. .1-74 1-7 4. <br />