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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> VOPTICE USE: 1601 E. Hazelton Ave. , Stochton, Calif. <br /> Telephone: (204) 466-6781 i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.-7 7-a,73 W <br /> f <br /> THIS PERMIT EXPIRES 1 YEAR FROM�.DATE ISSUED Date Issued Z: -- 7'7 <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- an& the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION -Z Iq d <br /> G( CENSUS TRACT <br /> Owner t s Name Phone <br /> r <br /> Address j All City Cti <br /> Contractorts Name (. 4 License # d Z Phone 6 2_ <br /> t � <br /> TYPE OF WORK (Check): NEW WELAALLATION <br /> /DEEPEN '/? RECONDITION /_7 DESTRUCTION Lam' <br /> PUMP IN / PUMP REPAIR '/ MENT <br /> PUMP REPLACE /7 <br /> Other L� <br /> f <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL AL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ', i Cable Tool _ Dia.. of. Well Excavation � <br /> Domestic/private i Drilled ° -- 'Dia. 'ofWell Casing ` <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection X Rotary Type of- Grout' ' G� <br /> Disposal ' Other Other Information <br /> -Ge ophysical. Surface Seal Installed- BY: <br /> i <br /> PUMP INSTALLATION: Contractor - <br /> Type of Pump H.-P. <br /> PUMP REPLACEMENT: %/ 9 State Work Done -: <br /> PUMP 'REPAIR: L7 State Work Done <br /> ES;TRUCTION 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 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 CALI. FORA GROUT INSPECTION <br /> PRIOR TO -GROUTING AN IINAL INSPECTION. <br /> SIGNED TITLE <br /> . (DRAW PLOT PLAN ON REVERSE SIDE " ��._ <br /> FOR DEPARTMENT_USE. ONLY- <br /> PHASE I <br /> APPLICATION ACCEPTEDf IV <br /> BY f��' DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT ASPECTION, PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 7 <br /> E H 1426 . Rev. 1-74 1-74 2M <br />