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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF <br /> OFFICE -USE: —� 1601 E. Hazelton Ave. , Stocktari; Calif. i <br /> Telephone : (209) 466--6781 / <br /> APPLICATION FOR WELL CONSTRUCTION OR PUNPjPERM TZ Rermit No. <br /> THIS PERMIT EXPIRES 1 YEAR PROM DATE ISSTJED-" 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 inyca pliance�w.ith, San Joaquin <br /> County Ordinance No. 1862 and`the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION O® Yy/ CENSUS TRACT <br /> Owner.',s Name Phone <br /> Address I/ xem 2 City <br /> Contractor's Name �� License fV <br /> Phone _ <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN _/ RECONDITION L/ DESTRUCTION /-7 <br /> PUMP INSTALLATION UMP. REPAIR / / PUMP; REPLACEMENT /- <br />: Other /. f <br /> DISTANCE TO NEAREST:". SEPTIC TANK ► SEWER LINES PIT PRIVY <br /> ..--SF <br /> ,WAGE 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 Tool Dia, of Well Excavation <br /> L,--Dbmestic/private Drilled Dia, of Well Casing <br /> Domestic/public 1 Driven Gauge of Casing Q <br /> Irrigation I Gravel Pack Depth of Grout Seal <br /> Cathodic Protection L,- Rotary Type of Grout <br /> �Disp'osal Other Other Information <br /> Geophysical ."- Surface Seal Installed By: sf <br /> PUMP INSTALLATION: Contractor <br /> r7 Type of Pump H.P. <br /> PUMP REPLACEMENT: ;/ / State Work Done <br /> Pit REPAIR. , ._� -- ­ <br /> / State Work Done <br />)ES,TRUCTION OF WELL: Well Diameters Approximate Depth <br />�a Describe Material and Procedure Y- <br /> t <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of Calif orni pertaining-tTa�or regulating well'construction. Within FIFTEEN DAYS <br /> after'completion of my work on a new well, .I will furnish the San JCpquin Local. Health District a <br /> WEi'L 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 />'RIOR TO{GROU --N D-.A-.,FINAL INSPECT <br /> STITLE <br /> ( RAW.-�'PTOT-PLAN ON' REVERSE_ SIDE) <br /> FOR DEPARTMENT USE'ONLY <br /> PHASE I <br /> kPPLICATION ACCEPTED BY DATE <br /> ADDITIONAL .COMMENTS: <br /> PHASE II GROUT INSPECTION PHASF, I /FINAL INSPECTION <br /> INSPECTION BY DATE - -,z '� INSPECTION BY DATE :. <br /> _H <br /> >~ wfi ' t, . ni 77 <br /> .-1426 Rev. � 1-74 - _ 2M <br />