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a SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF.:OFFICE E: 1601 E. Hazelton Ave. , Stocktbn, Calif. <br /> �/ ,. Telephone: (209) 466-6781 <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 hereby made to the Son Joaquin Local. Health District for a permit to construct <br /> unci/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/LOCATION D / CENSUS TRACT <br /> Owner's Name a_A6h, w Phone <br /> Address <br /> City <br /> Contractor's Name , License # &.2A Phone <br /> TYPE OF WORK (Check): NEW WELL/_7 DEEPEN '/-'J RECONDITION /_T DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT 1_7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SMR LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELA CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVADOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 0 <br /> Domestic/private ,Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> k Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Geophysical Other Information <br /> "_'"""�' <br /> Surface .— <br /> Seal Installed B . <br /> Lr, Oro <br /> PUMP INSTALLATION: Contractor L <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,REPAIR: <br /> Mate Work Done Aoc& ,e <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 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 y knowledge an belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO TING AND A FINAL_INSUCTVOJ. 110/ <br /> SIGNE <br /> �* 0_T1TLE <br /> (?RAW PLO LAN ON SE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY � s DATE ' Op- 2`J - 7J <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS9 II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE -77-7 6 <br /> E H 1426 Rev. 1-74 1./75 9M <br />