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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOf OFFICE USE: 1601 E. Hazelton Ave. , ,Stocktoin, Calif. <br /> Telephone: (209) 466-6781 r <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued - � <br /> (Complete In Triplicate) <br /> Application is Aereby 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 Jgaquinl <br /> County Ordinance No. 1862 andt�he` Rut and Reg a of the San Joaquin Local Health District, <br /> JOB ADDRESS/LO ON CENSUS TRACT <br /> 01 <br /> Owner's Name Phone <br /> i <br /> Address Y.,A. <br /> Contractor's Name License/� 3'_3Ph0ne <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITI /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR 47PUMP REPLACEMENT 17 <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 <br /> Industrial Cable Tool '' Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary a Type of Grout �J <br /> Disposal Other Other Information — <br /> Geophysical Surface Seal Installed By:_ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done dn <br />' PUMP `REPAIR: State Work Don <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 bistrict <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 CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED �_�_, TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDEY <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ' <br /> APPLICATION ACCEPTED BY DATA <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSP TION PHAS /F NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY 4 DATE <br /> u� v I674 n___ i 7/. <br />