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'y SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave . , Stocktcla,' Calif. <br /> Telephone: (209) 466--6781 <br /> r) PLICATION 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 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. 1862 and the Rules and Regulations of the San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION r' CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address !�Z City _C <br /> Contractor's Name �� �- / License � .� <br /> �c9o/ Phone .- <br /> z 17 �1 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION /7 DESTRUCTION /`7 <br /> PUMP INSTALLATION PUMP REPAIR/ f PUMP REPLACEMENT /- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation / <br /> y{ Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal 1>7-21 <br /> Other Rotary Type of Grout _f-- <br /> - Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done {� <br /> PUMP REPAIR: / J "State Work Done <br /> ,PESTRUC_TI.ON 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 REPO f the well and notify them before putting the well in use. The above <br /> information i ue to the f m nowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SI <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY � t � DATE �Z--- <br /> ADDITIONAL COMMENTS: . „— <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE "' INSPECTION BY DATE <br /> CALL FOR A QUT INSPECTION PRIOR TO GROUTING AND FINAL INSPE610N. <br /> E H 1426 4/72 1M ca- <br />