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SAN JOAQUIN LOCAL, HEALTH DISTRICT <br /> FOF:.OFFICE USE: 1601 E. Hazelton Ave. , ,Star_kton-f Calif. <br /> #.A Telephone : (209) 466-6781 <br /> APP ICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued 7 <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 Joa uin Local Health District. <br /> JOB ADDRESS/LOCATION NSUS TRACT <br /> Owner's Name Phone �/'j_ <br /> Address L CAI E f 1 EE City _�����= <br /> Contractor's Name License #11C).2Z Phone _ S (� <br /> i <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/ / RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR /- / PUMP REPLACEMENT /_7 <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 TYPE OF WELL CONSTRUCTION SPECIFICATIONS `U <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> -Dome sti-c/public- -'Driven�- _ "� �"-Gauge of Casing <br /> Irrigation y Gravel Pack Depth of Grout Seal Q <br /> Cathodic Protection Rotary Type of Grout _ —� <br /> Disposal Other Other Information --- <br /> Geophysical Surface Seal Installed B : E <br /> yY1���xfb <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <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 <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 <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 GROUTI G 2 A FIN SPECT:ION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR EPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION -ACCEPTED BY DATE A 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION I P III/FI INSPECTIO <br /> INSPECTION BY DATE INSPECTION B DATE <br /> E H 1426 Rev. 1-74 - - <br /> 11/77m . 2M <br />