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N1_ <br /> r SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR:OFFICE USE: 1601 E. Hazelton Ave. ,.e toclttbn, Calif. <br /> Telephone: (209)' 466-6783. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 7 -3�VW <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/LOCATION I /r CENSUS TRACT <br /> Owner's Name �...� !_.�1 ` _ Cos Phone , iv3 s <br /> Address City . . } <br /> Contractor's Name ,License # Phone <br /> TYPE OF WORK (Check): NEW WELL / f DEEPEN '/? RECONDITION F7 DESTRUCTION /-T <br /> "' PUMP INSTALLATION/ / PUMP REPAIR'/ J PUMP REPLACEMENT /? <br /> Other <br /> f — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ; <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ' k <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 /> -Domestic/private Drilled Dia. of Well Casing " � s <br /> Domestic/public Driven Gauge of Casing D i <br /> Irrigation Gravel Pack Depth of Grout Seal ffv ' <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ' <br /> Geophysical Surface Seal Installed By: � <br /> PUMP INSTALLATION: Contractor �C f <br /> Type of PUMP H.P. <br /> PUMP REPLACEMENT /-7 State.Work Done x <br /> PUMP REPAIR: / Store Work .Done <br /> .41 <br /> DESTRUCTION OF WELL: Well. Diameter Approximate Depth <br /> Describe Materi,gl and Procedure <br /> } <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 i <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 j <br /> information is true to the- of my.knowledge and belief. I WILL CALL-'FOR A GROUT INSPECTION <br /> PRIOR TO GR NG ANDA FINbe SPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) �-" <br /> - _ FOR DEPARTMENT USE ONLY -•---- - -_ <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III F NAL INSPECTION <br /> INSPECTION BY TE INSPECTION BY DATE <br /> E H -1426 <br /> Rev. 1-74 <br />