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G p SAN JOAQ)UIN LOCAL HEALTH' DISTRICT <br /> j • FOR!'OFFICE USE: 1601 E. Hazelton Ave. ; 'Stocktbn, Calif. <br /> l Telephoner (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S-27TW <br />} THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the. San Joaquin Local Health District. <br /> JOB ADDRESS/LOCAT ON S' CENSUS TRACT <br /> Owner's Name Phone <br /> Address City <br /> F ` <br /> Contractor's Name License # Phone <br /> TYPE OF WORK (Check): NEW WELL /-7 DEEPEN -/-7 RECONDITION /7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR IX—PUMP REPLACEMENT /7 <br /> ° Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY pb <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL O <br /> INTENDED. USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled f. Dia. of Well Casing <br /> ;Domestic/public Driven Gauge o£ 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 $ : <br /> i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: LVI State Work Done e7 1141 -4144*1A I <br /> PUMP `.REPAIR: /-7 State Work Done <br /> PES,TRUCTION OF WELL: Well Diameter Approximate Depth <br /> 4 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 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'GROUT INSPECTION <br /> PRIOR TO GROUTING AND A F NAL INSPEgElON. <br /> SIGNED TITLE <br /> . (DRAW PLOT PLAN ON REVERSE SID N <br /> ' FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE r <br /> ADDITIONAL COMMENTS: <br /> PHASE II C90VT INSPECTION PHASE II (FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE *'ZZLI <br /> E H 1426 Rev. 1-74 1_74 <br /> f - -- <br />