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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO1�ZFFICE USE: 1601 E. Hazelton '.Ave.:";:`'Stack ' Calif. <br /> Telephone: _(209).14664781- <br /> APPLICATION <br /> (209) 466=5781APPLICATION FOR WELL CONSTRUCTION OR PUNT' PERMIT Permit No. <br /> THIS PERMIT EXPIRESj- YEAR FROM'-DATE ISSUED Date Issued <br /> (Complete:Tn;Tripl'i:cate): <br /> Application 16 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 Na.' 1862 and rhe Rules and, Regulrations,.of,the .San Joaquin Local Health District. <br /> .TOB ADDRESS/LOCATION � .. �'�'':' "' <br /> G CENSUS TRACT <br /> + Owner`s NamePhone . 9-3 1 <br /> Address _�� 0-A� �;, :.S`j ,.. City . <br /> ' License # Phone 4 O <br /> Contractor's Name Q <br /> I 4 94 <br /> TYPE OF WORK (Check): • NEW WELL DEEPEN J7. RECONDITION DESTRUCTION /- � <br /> PUMP INSTALLATION / / PUMP REPAIR /_7 PUMP REPLACEMENT 1_7 <br /> Other / / <br /> t - <br /> DISTANCE TO NEAREST: SEPTIC TANK p , SEWER LINES/.Q rjPIT PRIVY _ <br /> SEWAGE DISPOSAL FIELD r 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 4210 <br /> Domestic/private Drilled Dia. "of Well Casing (,)J <br /> Domestic/public Driven _Gauge of,_Casing )1 Q► <br /> x. Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary -Type of Grout <br /> Disposal Other Other,. Information _ <br /> Geophysical ` Surface Seal Installed By: <br /> PUMP INSTALLATION; Contractor <br /> Type;of Pump -5L8- Zh 44 .1143Lt= H.P. e.7 <br /> PUMP REPLACEMENT: / ./ State Work Done <br /> PUNP .REPAIR. /7 State Work Donee <br /> I ,SES;TRUCTION OF WELL: Well Diameter Approximate Depth <br /> I 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 th est af. my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GAN A INSPECTION. A.— <br /> SIGNED TITLEG�' <br /> (DRAW PLOT PLAN ON-REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II CLOUT INSPECTION PHASE III{FINAL INSPECTION <br /> INSPECTION BY DATE ~'` 7 INSPECTION- BY �^�' ,r DATE <br /> i EH 1426 Rev. I-74 1-74 <br />