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�� ..a�� <br /> ^4 �l✓ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF�:OFFICE USE: 1601 E. Hazelton Ave. ,. Stockcon, Calif. <br /> Telephone; (209)' 466--6781 //� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Per <br /> 4niC No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED <br /> Date' Issued <br /> (Complete In Triplicate) .0 5-3 <br /> -permit t�construct <br /> r� <br /> hpplidddion is hereby made t6 the Son Joaquin Local Health District for a <br /> and/or installthe work herein described. This application is made in compliance with San-Joaquin <br /> County Ordinance No. 1.862 and the Rules and Regulations of the Saar Joaquin Local Health ,bistrict. <br /> f ! <br /> JOB ADDRESS/LOCATIONTdNSUS TRACT <br /> E <br /> Owner"s Name Phone <br />-Address <br /> City ? <br /> Contractor's Name r <br /> License #/ Phone ' <br /> TYPE OF WORK (Check): NEW WELL,-/-7 DEEPEN -/7 RECONDITION /7 DESTRUCTION f7 <br /> PUMP INSTALLATION/_7 PUMP REPAIRPUMP REPLACEMENT /7 . <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 k <br /> 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 r Depth of, Grout Seal <br /> Cathodic Protection Rotary-,-,'--, Type of Grout <br /> DisposalOther ' Other Information <br /> Geophysical <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 4 <br /> H,P. 22 A <br /> PUMP REPLACEMENT. ry j <br /> F' <br /> Stag Work Done 4- <br /> PUMP '.REPAIR: / State Work Dore f <br /> P 4 �0 <br /> DESTRUCTION-OF-WELL. •-._,.Wel- --Diame-ter <br /> 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 regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish thej$an Joaquin Local Health District a <br /> WELL DRILLERS REPORT .of the well and notify them before putting the.-well- in-use.'... The above <br /> Lnformation ig,,True to the.b t .of my.knowledge and belief. ' I WILL CALL FOR-A 'GROUT INSPECTION <br /> 112LMIE944G OD A rINAVIN' SPECDJON. ` <br /> SIGNED <br /> TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br />'RASE I FOR DEPARTMENT USE ONLY <br />&P CIL ATION ACCEPTED BY <br /> IDDITIONAL COMMENTS.- DATE <br /> f PRASE II GROUT INSPECTION f <br /> INSPECTION BY PHASE III FINAL INSPECTION <br /> DATE INSPECTIOd BY DATE <br /> E H 1426 Rev. .1-74 f <br />