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;APJ '-', ''TST?ICT <br /> L.FOR OFFICE USE: _LoOl E_ H-_-_, Lon hv. , , StockLc:k, Calif. <br /> `� Telephone: (20 ) 11.66-67181 1 <br /> APPLICATION FOR WELL CONST-RUCI'ION OR PUIvJ.) PERMIT Permit No. ,f�'� <br /> LTHIS ERMIT EXPIRES 1 YEAR T';:OM D :TE ISSUED Date Issued i <br /> (Complete In Triplicate) <br /> pplication is hereby made to Plie San Joaquin Local Health District for a permit. to construct <br /> end/or install the work herein described. This application is made in compliance with San Joaquir <br /> Count• Ordinance No. 1862 and the tiles and Regulations of the San Joaquin Local Health District. <br /> `OB ADDRESS/LOCATION CENSUS TRACT <br /> -wner's Name e� Phone -77f' :? <br /> 'Tddress <br /> f. <br /> City:___ <br /> ontractor's Name /� '�[". _ r :. License Zfi Phone <br /> YPE OF WORK (Check) : NEW WELL /t;el4 DEEPi;N / / RECONDITION /_/ DESTRUCTION /_7 _ <br /> PUMP INSTALLATION _PUM REPAIR / / PUMP REPLACEMENT <br /> Other / __7 <br /> ISTANCE 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 /> sj�_ Domestic/private Drilled Dia. of Well Casing _' <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal -� <br /> Other Rotary Type of Grout �- <br /> Other Other Information <br /> i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump _: w H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> rMP REPAIR: / / State Work Done <br /> nFSTRUCTION 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 /> d 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 /> WELL DRILLERS REPORT''of the well and notify them before putting the well in use. The above <br /> formation <br /> -_is_,,_t'rue to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) r <br /> PT4P,S E I FOR DEPARTMENT USE ONLY <br /> kPPLICATION ACCEPTED BY DATE <br /> DITIONAL COMMENTS: <br /> PHASE GROUT INSPECTION_/ PHASE III/FINAL INSPECTION <br /> INSPECTION BY+C,r DATE i o /.� 1 INSPECTION BY -' DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION.' <br /> E H 1426 4/72 1M <br />