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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL'OFF CE u5, : Ll e. 160.1 E. Hazeltor, Ave. , Stocktolft, Calif. <br /> Telephone: (203) 466-6781. <br /> APPLICATION FOR. WELL 'CONSTRUCTION .OR PUMP .PERMIT Permit No.. <br /> THIS PERMIT EXPIRES :I 'YEAR PROM DATE ISSUED Date Issued z,L 71_ <br /> �»- .(Couplete In Triplicate) <br /> ;pp]ication is her by made to the San Joaquin Local Health.District for a permit to cottetruct <br /> incl/.or iiistali the`; worm herein described'. This application is made in compliance with San Joaqui <br /> :out'ty Ordinance Ido. 1862 and the Rulee an'd Regulations of the San Joaquin Local Health District'. <br /> rOB ADDRESS/LOCATION CENSUS TRACT <br /> owner's Name _ /! w _ Phone _ _ ��� � w <br /> ddress y _ � City , <br /> Detractor`s Name '_„4 '` <br /> License J .3 Phone � Sh <br /> �i <br /> Yn' OF WORK (Check) -i NEW WELL -//_� DEF,FEN ' RECONDITION j�7 D1:STRTJC�'IOid !-7 <br /> " PUMP INSTALLATION /"J PUMP REPAIR / I'UMP REPLACEMENT /? <br /> Other <br /> ISTANCE TO: NEAREST: SEPTIC "ANI{ SEWER LINES PIS' PRIVY <br /> SEWAGE DISPOSAL CESSPOOI,/SEEPAGE PTT-- - OTHER <br /> PROPERTY LINE •- PRIVATE ?DONESTIC WELL PUBLIC DOMESTIC WELL: <br /> INTENDED USE'. TYPE OF WELL C NO STRUCTION SPECIFICATIONS <br /> Industriali` <br /> Cable Tc+a1; This. ofWell Excavation � <br /> Domesti. Drilled.: Dia. of Well 'Casing <br /> Domestic/pubic Driven Gauge of Casing <br /> Irrigation. Gravel Pack Depth of Grout Seal <br /> Cathodic Prot action -- Rotary Type of. Grant r� <br /> v_. ..._ <br /> Disposal Other Other Information _ <br /> Geophysical --- SurfaceSea Installed 'By: <br /> JMP'�INSTALLATION: Contractor <br /> Type of Pump <br /> r <br /> TMP'REPLACEMENT: / / State Work Done <br /> IMP :-REPAIR,. State Work Done ' , <br /> &TRUCTION. OF WELL: Well Diameter Approximate Depth <br /> Describe Material and' Procedure <br /> hereby agree to comply with all laws and reghlations' of the .San .Joaquin Local Health District <br /> A the State of California pertaining to `'Or regulating well 'construction. Within FIFTEEN DAYS <br /> ter completion of. my work on a new well,, I will furnish the San Joaquin Local Health District a <br /> i ;LL iDRILLERS REPORT of the well and notify them before petting. the .well, in use.... The above <br /> .formation :is true- to the•best of my.knowledge. and belief_ : I WILL CALL FOR A -GROUT INSPECTION <br /> IORITO GROUTING AND .A FINAL INSPECTION. <br /> GNED TITLE. ')? <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> ASE I' !' <br /> PLICATION ACCEPTED BY <br /> DATE °?S <br /> DITIONAL COMMENTS:: <br /> PHASE 3.I I SP TIC. FHASIJOIJFINAL INSPECTIOlk <br /> SPECTION BY - DATE �� INSPECTION BY DATE ZZ r <br />