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c v JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOE OFFICE USE: 160*.., . Hazelton Ave. , ,Stotkton, Calms <br /> Telephone : (204) 466-6781 <br /> APPTKATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, <br /> HIS 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 Joaquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Z�SUS <br /> Local Health Diatr�ct. <br /> JOB ADDRESS/LOCATION ('A /i, ,,d� Csa..-fi IIA, ?Se.O'A/ TRACT <br /> Owner's NameLr„ �� L /"-/-1/InAt Phone <br /> Address /4.�n E Lo ,s 7ajrL led City <br /> Contractor's Name p&rtzO `! Z2/"I License Phone 5 (6 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /% RECONDITION /_7 DESTRUCTION /_] <br /> PUMP INSTALLATION / / PUMP REPAIR /7 / PUMP REPLACEMENT /_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ^ <br /> 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 _X Cable Tool Dia. of Well Excavation 14 <br /> Domestic/private Drilled Dia, of Well Casing _/ l' <br /> Domestic/public Driven Gauge of CasinguNLI <br /> Irrigation Gravel Pack Depth of Grout Seal v <br /> Cathodic Protection Rotary Type of Grout _ ft <br /> 6� <br /> Disposal Other Other Information l <br /> Geophysical Surface Seal Installed By: <br /> �aolLlf6 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State.Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure T— <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 <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 GROUT I G A4D A FIN NSPECTION. � <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR PEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE, Ij GROUT INSPECTION I P III/FI INSPECTION <br /> INSPECTION BY 417SL DATE INSPECTION Byz DATE <br /> . 1177 eu <br />