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SAN JOAQUIN LOCAL 'HEALTH DISTRICT <br /> FOR•!OFFICE USE: 1601 E. Hazelton Ave. , 'Stoe.kton, Calif. <br /> !Kit <br /> Telephone; <br /> I� P (209). 465-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR:FROM DATE ISSUED Date Issued )y_47_7(, <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. 1852and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �. . <br /> CENSUS TRACE <br /> OwnerQS Name <br /> Phone -� - — <br /> Address i �- <br /> j� City <br /> Contractot. Name .a e� License # <br /> IjCt Phone <br /> lj <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN/7 RECONDITION / ' DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR /_77P UMP REPLACEMENT /7 <br /> Other /7 -._. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> j SEWAGE DISPOSAL FIELD 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 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge o£ Casing . <br /> „ Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> —Disposal ., Other <br /> Other Information � <br /> Geophysical Surface Seal Installed By: 1 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump , <br /> H.P. <br /> PUMP REPLACEMENT: <br /> j//_ State Work Done !� <br /> PUMP REPAIR: /? State Work Done _ <br /> II <br /> E&TRUCTION OF WELL: Well Diameter <br /> Describe Material and—Procedure Approximate Depth i <br /> I hereby agree to comply with all laws and regulations of the San- Joaquin Local He.a <br /> lth <br /> and the State of California pertaining to or regulating well construction. Within FIFTEENtrict DAYS i <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 /> informatioriiis true to the-best-of my knowledge .and belief. I WILL L FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING FINAL�INSPECfto�NSIGNED TITL(DRW PLOT PLAN ON REVERSE SIDE <br /> PHASE I F2R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE �Q <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY PHASE I I NAL INSPECTION <br /> - DATE y INSPECTION BY DATE <br /> 76 <br /> E H 1426 Rev. 1-74 <br /> - 1-74 7M G <br />