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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORrOFF'ICE USE: 1501 E. Hazelton Ave. ,�Sto4p_on, Calif. <br /> Tele� hone:P (209) 466-6781 <br />'. APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZL16f 7&) <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application 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. 1852 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name �,Q�.• _. _� <br /> Phone 7b 71 <br /> Address City <br /> Contractor's- Name License Upp Z fftone 6�� <br /> _.TYPE-OF WORK (Check) : NEW WELL�'Ly DEEPEN '/� RECONDITION-'/7 DESTRUCTION /_7 <br /> PUMP INSTALLATION /,P,/'—PUMP REPAIR /-7—PUMP REPLACEMENT /-7 J <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK /Qp ' SEWER LINES PIT PRIVY �I <br /> SEWAGE DTSPOSAL ,FiELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINEJO.RI NATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF HELL" CONSTRUCTION SPECIFICATIONS I <br /> Industrial f Cable Tool, Dia. of Well Excavation �! I <br /> Domestic/private Drilled ' I?, Dia. of Well Casing <br /> DonnesticlfpublieDriven n Gauge yofT Casing.- <br /> Irrigation Gravel Pack' Depth of Grout Seal -df J ; <br /> : Cathodic Protection Rotary* Type of Grout ,,_,p� (� <br /> Disposal OtherInformation--- - - - <br /> Other <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor � <br /> Type of ,Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP_:!REPAIR - _ <br /> -- ��. _ -..�--, - ,_ �•: - �,,"_..� _ ���--�. <br /> ES�TRUCTTON OF WELL: .� one <br /> -- -- - � <br /> 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 regulat.ing.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 GRD TING AND A F NAL INSPECTION. <br /> SIGNED WTITLE <br /> (DRAW PLOT <br /> AN ON REVERSE SIDE U <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> II ROUT INSPECTION ;� NAL INSPECTION <br /> INSPECTION BY DATE2=425 S INSPECTIO BY 7- DATE <br /> E H 1426 Rev. 1-74 , <br />