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r - <br /> SAN JOAQUIN LOCAL -HEALTH DISTRICT <br /> _70T"OFFICE -USE: 1601 E. Hazelton Ave;,,Stoc'kt6n, Calif. <br /> ' <br /> Telephone: (205)_4661-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PULP PERMIT ,Permit No. SS <br /> THIS PERNIT EXPIRES l-YEAR-k'ROMr,DATE' ISSUED Date Issued <br /> j : : (Complete. In-Triplicare) <br /> Application is hereby made to the San Joaquin Local .HealthaD istrict fora permit to'construtct <br /> and/or install Che work herein described. This ..applicatiori.is.,made in compliance with-;San Joaquin <br /> County Ordinance No. 1862 and. the Rules and . gulations�of.`the 'San Joaquin Local Health District. <br /> CENSUS TRACT <br /> Owner r s Name �y 1-t--/� 4 Phone <br /> F{}� Address -� 6' � � ' ,�. City5 <br /> . Contractor's Name ' 1/ 7 J s License #Aa 37F�one hF6d��a <br /> s <br /> . .TYPE OF WORK (Check): NEW WELL /7 DEEPEN -/-7 -RECONDITION DESTRUCTION f7 <br /> PUMP INSTALLATION, / / PUMP REPAIR f PUMP REPLACEMENT <br /> �. Other /-7 <br /> DISTANCE TO NEAREST: . SEPTIC TANEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL. FIEIbI CESSPOOL/SEEPAGE PIT OTHER <br /> x: PROPERTY LINE -- PRIVATE DOMESTIC WELL_ PUBLIC DOMESTIC WELL <br /> INTENDED USEJ TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial k� Cable Tool Dia. of Well Excavation <br /> Domestic/private ;t. Drilled = Dia. of Well Casing <br /> -Domestic/public ? Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> ` Cathodic Protection -1- Rotary Type -of Grout <br /> Disposal 1 Other Other .Information <br /> Geophysical 1 Surface Seal Installed By: <br /> PUMP- INSTALLATION; Contractor _ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP- REPAIR: -----= --��/--7- State-work-D <br /> „UES RUCTION 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 :r' <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-beat of my.knowledge and belief. I WILL CALL FOR A -GROUT INSPECTION <br /> i PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNEDI� 7�_L� l/') TITLE <br /> i. (DRAW PLOT PLAN ON REVERSE SIDE <br /> F01t DEYARTMWT USE ONLY <br /> i PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUTiINSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY 'DATE INSPECTION BY DATE /iGL 7 S <br /> °1-74 2M ' <br /> I " E H 1426 Rev. 1=74 � f:= <br />