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SAN JOAQUIN LOCAL HEALTH DISTRICT . , + <br /> FOE'OFFICE USE: 1601 E. Hazelton Ave. , Stocktoni* Calif. ° <br /> Telephoner, (209) 4,66--67814 �¢ j <br /> APPLICATION'+FOR WELL CONSTRUCTTON OR PUIyIPi,P IT Permit No. jO <br /> THIS `-PERMIT EXPIRES 1 YEAR FROM DATE �ISSJE'D Date Issued {�� <br /> .r 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,des`crib ed. :This application is made. in compliance with San._Joaquin <br /> County Ordinance No. 1862 andithe:ARules. and Regulations of,. the. San Joaquin Local Health. District. 0 <br /> JOB ADDRESS�/LOCATION 1, . M / �5 TRACT — <br /> ne <br /> Owner's Name , 8> +� sEhg <br /> - . <br /> Address -City <br /> Contractor's Name _ ..:Z LicensePhonet <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION / /. DESTRUCTION <br /> PUMP INSTALLATION / / PUMP., REPAIR / / PUMP -REPLACEMENT <br /> �,.. Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK �� SEWER LINS+ "..PIT PRIVY. <br /> t; , <br /> SEWAGE DISPOSAL FIELD JOL-0 CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTICWELL .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-,_471, O <br /> Domestic/public Driven Gauge of Casing ry 7 <br /> Irrigation Gravel Pack, Depth ofrGro'iit-,,Seal <br /> Cathodic Protection Rotary *- Type of Grout <br /> ,. <br /> Disposal Other .' Other Information <br /> GeophysicalSurface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type o'f PumpH.l'.lot <br /> I - - - <br /> PUMP REPLACEMENT: / / State Work Done _ i14L-) --- <br /> f PUMP .REPAIR: / / State Work Done <br />, DESTRUCTION OF WELL: Well Diameter ,Approximate Depth <br /> E Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local health Distract <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 1the 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 rue to the best of my knowledge' and belief. I WILL CA4 FOR A GROUT INSPECTION <br /> PRIOR TO GROU G AND A L INSP TION, `` <br /> SIGNED TITLE - <br /> (DRAW PLOT PLAN ON REVERSE SID :.. :•et., <br /> FOR DEPARTMENT USE ONLY <br />["PHASE I <br />; APPLICATION ACCEPTED BY x DATE <br /> F ADDITIONAL COMMENTS: <br /> x PHASE II GROUT INSPECTION P E I/ NAL INSPECTIO � <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> .� 2M . <br /> E H 1426 Rev. - I-74 . 6177 .__ u .t- <br />