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- SAN JOAQUIN LOCAL HEALTH STRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stoc on, Cali <br /> Telephone : (209) 46 --6781 <br /> APPLICATION FOR WELL CON TRUC ON 10 IT Permit — _,�/ <br /> THIS PERMIT EXPIRE R <br /> SSUED Date Issued ,2&—x <br /> I cat <br /> alt District for a p rmit to construct <br /> Application is hereby made to the Sa quzri Lo Joaquin <br /> and/or install the work herein de ed. This is ion is made in compliance with San <br /> County Ordinance No. 1862 and the Rules and Reg ti <br /> s of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION s CENSUS TRACT ' <br /> Phone <br /> Owner's Name <br /> City _ <br /> Address <br /> Contractor's Name License '��hon .. <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDgTION / / DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAR / PUMP REPLACEMENT /� <br /> _ Ci <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> t SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DGASTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> j Industrial Cable Tool Dia. of Well Excavation . <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing O <br /> Irrigation ��' <br /> Gravel P ck Depth of Grout Seal <br /> Cathodic Protection ��( Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pum <br /> PUMP REPLACEMENT: /with <br /> tat Work Done <br /> PUMP :REPAIR: to Work Done <br /> DESTRUCTION OF WELL: iameter Approximate Depth <br /> be Material and Procedure <br /> I hereby agree to coall laws and regulations of the San Joaquin Local Health District <br /> and the State of Calertaining to or regulating well "construction. Within 'FIFTEEN DAYS <br /> after completion of n a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORTell and notify them before putting the well in use.... The above <br /> information is true st of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> TITLE <br /> SIGNED (DRAW PLOT PLAN ON REVERSCA L/cr <br /> E SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> ". PHASE IVDATE 6 <br /> APPLICATION ACCEPTED BY <br /> r ADDITIONAL COMMENTS: P SE Ill./FINAL INSPECTION <br /> PHASE-lI DUT IN ECT ON DATE ✓/' <br /> INSPECTION BY DATE f INSPECTION B <br /> u 1L9A Ray. , 1-74 f _ <br />