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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOF OFFICE USE. 1601 E. Hazelton Ave. , St6ckton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> - _ � <br /> f THIS PERMIT MIRES- 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 /> f County Ordinance No. 1862 and the Rules and gulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �, r r CENSUS TRACT <br /> Owner's Name r ems' Phone <br /> k Address , City-'' " <br /> Contractor's Name ice n e Phone <br /> r <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_T <br /> PUMP -INST LATION REPAIR/ / PUMP REPLACEMENT 177 <br /> E Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESPIT PRIVY, i <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 Cable Tool Dia. of Well Excavation \ <br /> v <br /> ,Domestic/private I—Drilled Dia. of Well Casing C <br /> r---- Domestic/public Driven Gauge of Casing <br /> Irrigation--~- ---Gravel Pack_ _-Depth af-Grout-Sea­1---" <br /> Cathodic Pro tec -cam`=notary- „.__Type_o.f._Grout. <br /> I Disposal., Other Other Information ` <br /> Geophysical Surface Seal Installed B : ' <br /> rPUMP INSTALLATION: Contractor <br /> Type'.lof Pump a. t i H.P. x <br /> PUMP REPLACEMENT: / / State Work Done`' <br /> PUMP �.REPAIR: / / State Work Done <br /> 4 <br /> . DES-TRUCTION OF WELL: Well+Diameter Approximate Depth <br /> Desctibe Material and,-Procedure <br /> I hereby agree to comply with all lams 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 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 U ING AND_.A FINAL INSPECTION. ' <br /> t SIGNS TITLE / <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> t „ FOR DEPARTMENT USE ONLY <br /> PHASE I ; <br /> ' APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION <br /> PHASE III/FINAL INSPECTION <br /> INSPECTION�BY DATE -�. INSP�:CTION BY DATE <br /> _ DerLC,d�n SATO q//o � -7 '7, Dv7' 0 1/77. _ <br /> E H 1426 Rev. 1-74 Ale �/'C'CJu7 <br />