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i! Ii <br /> SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOF OFFS�CE'.:USE: 1601 E. Hazelton Ave. Stock <br /> , ton,2 <br /> Calif. <br /> r Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR'fPUMP PERMIT Permit No. <br /> 11 <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' <br /> ,fis made in compliance with San Joaquii <br /> County Ordinance No.,.1862 and 'the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION.. . . CENSUS TRACT <br /> Owner's Name " <br /> Phone <br /> ,r <br /> Address �_ �� City <br /> Contractor'AL <br /> Name E LicenseIt Phone <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN ,/ / RECONDITION /_/ DESTRUCTION /- <br /> PUMPI INSTALLATION <br /> _ / / PUMP REPAIR / !�/ PUMP REPLACEMENT 15? <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 <br /> INTENDED USE iTYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> f Industrial Cable Tool Dia. of Well Excavation <br /> C _ Domestic/private Drilled Dia. of Well Casing, <br /> t Domestic/public Driven Gauge of ,Casing <br /> Irrigation Gravel Pack Depth of 'Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> t Disposal Other Other Information <br /> k Geophysical Surface Seal Installed$ : <br /> E <br /> PUMP INSTALLATION: Contractor — � -- - <br /> y TYPet. Pmp d 4 / <br /> PUMP REPLACEMENT: State•Work Done <br /> k, PUMP �REPAIR:I _ / / State'•Work Done �! - <br /> fDES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> 3 Describe Material and Procedure <br /> 1 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 welilconstrudtion. Within FIFTEEN DAYS <br /> ; after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> SWELL DRILLERS REPORT of the well and notify them before putting thewell in use. The above <br /> information is true to the best of my knowledge and belief, �jI WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROVYIN9 .AND A FINAL INSP CT N. <br /> SIGNEDTITLE L ✓ <br /> (DRX1W PLOT PLAN ON REVERSE SIDE) <br /> } i FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> .!PHASE II GROUT INSPECTION PHAS /FIN INSPECTION <br /> INSPECTION .BYDATE INSPECTION.BY' DATE �� <br /> ii. <br /> E H 1426 Rev. 1-74 - _ _ �! I 1 Z7 4 :2m <br />