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SAN JOAQUIN LOCALHEALTHDISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stotkton, Calif. <br /> Telephone,: (209), 466-6781 <br /> APPLICATION FOR WELL\CONSTRUCTION OR PUMP PERMIT Permit No.7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued?`'l6-? <br /> (Complete In Triplicate) <br /> iApplication 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 Joaquin Local Health District. <br /> JOB ADDRESS �1 e� CENSUS TRACT <br /> Owner's Name Phone <br /> E Address f City <br /> Contractor's Name Licensehone�. r' <br /> k i <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN/ / RECONDITION /% DESTRUCTION /_7 <br /> PUMP INSTALLATION I PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TAN d SEWER LINES PIT PRIVY ' <br /> SEWAGE DISPOSAL IELD1 CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINF-- RIVATE DOMESTIC WEL _&4_/ PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> �(1 Domestic/private Drilled Dia: of Well Casing rJ <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal Ar 10 <br /> Cathodic Protection X Rotary Type of Grout ' <br /> Disposal - Other Other Information <br /> Geophysical Surface Seal Installed_ By: _ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.F. <br /> _ I -- <br /> PUMP REPLACEMENT: / / State Work Done <br /> ` r <br /> PUMP REPAIR: -'} I <br /> / / State Work Done <br /> DESTRUCTION OF WELL: Well-Diameter ` IA <br /> -. 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 pertaiizing �to orregulating well 'construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well; 1--will furnish the San Joaquin Local Health District a <br /> WELL 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. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION <br /> SIGNED <br /> PL T P AN ON REVERSE SIDE) �v <br /> PHASE I <br /> FOR D ARTMENT USE ONLY <br /> [� -- - . �- - -dAPPLICATION ACCEPTED BY ` R DATE y 7 y <br /> ADDITIONAL COMMENTS: - --- - ;. <br /> P SE GROUT NSPECTION PRASE ,UI/FINa INSPECTIO <br /> INSPECTION BY DATE p INSPECTION DATE 7` <br /> E H 6 /d 7 I t <br /> 14.2 _ -Rev. 1�(4 '� ��'� A44- �fj .�'� U77 V '� <br />