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f SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0E-i OFFICE USE.,: 1601 E. Hazelton Ave„ ,-Sf6ckton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Na. �L 7 5 <br /> THIS PERMIT- EXPIRES 1 YEAR FROM DATE ISSUED Date Issue <br /> a <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health Distrix. ' <br /> { <br /> JOE ADDRESS/LOCATION a�O s� �cs� �i• CENSUS TRACT <br /> y <br /> Owner's Name C f �� Phone <br /> Cit <br /> Address S 7-0,J <br /> y <br /> License �� d 'hone <br /> Contractor's Name p A 2�lI �. _ <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN I I RECONDITION f I DESTRUCTION /-7 <br /> PUMP INS ALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES -g PIT PRIVY..-d. � € <br /> SEWAGE DISPOSAL FIELD � CESSPOOL/SEEPAGE PIT -4%. OTHER <br /> - <br /> PROPERTY �i�INE- � 1 <br /> a�PRIVATE DOMESTIC'-WELL” �: —PUBLIC-F07 ESTIC WELL' <br /> -- <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS a 1V <br />` Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Y Drilled Dia, of Well Casing fo <br /> Domestic/public Driven Gauge of Casing / .0 '€ <br /> Irrigation �ox Gravel Pack Depth of Grout Seal d <br /> 4. <br /> Cathodic ProtectionRotary Type of Grout <br />' Disposal Other Other Information <br /> Geophysical Surface Seal Installed B /40tsrG f <br /> -PUMP INSTALLATION: Contractor zd ' <br /> ,~ Type of Pump w. a H.P. - <br /> t <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP -.REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well .Diameter Approximate Depth . <br /> Describe Material and Procedure 4 ! <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 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 is true to the best of my knowledge and belief. I WILL CALL FOR A GROAT INSPECTION <br /> PRIOR TOX-ROUTING=-AND_A­:FINAL:--I- -CT10N.­ <br /> SIGNED TITLE j <br /> ol <br /> (DRAW PLOT .PLAN ON REVERSE SIDE) ! <br /> FOR DEPARTMENT USE ONLY j <br /> PHASE I <br /> APPLICATION ACCEPTED BY GdG-- DATE <br /> #'ADDITIONAL COMMENTS: <br /> PHASE II G UT INSPECTION / PHASE II /FINAL INSPECTION <br /> INSPECTION BY { DATE ,7 INSPECTION BY -9!- <br /> - ti 0/77. - 2M <br /> y / _ , <br />