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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORrOFFICE USE: 1601 E. Hazelton Ave. S <br /> tocktpn, Calif.CaJ.if <br /> Telephone: (209) 466-6781 7S` fg7l ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PULP PERMIT Permit No. 3?s W <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 :Wade 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 ,�� ��, /� CENSUS TRACT <br /> Owner's Name � E � Phone d <br /> 711 <br /> Address Citq ��2rr <br /> Contractor's Name License #-Z*;W'Phone <br /> TYPE OF WORK (Check): NEW WELL/ DEEPEN /7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION 6? PUMP REPAIR / / PUMP REPLACEMENT /? <br /> } Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK 04-SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINEAL PRIVATE DOMESTIC WELL PUBLIC DOMESTIC TIC WELL }� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �F-' 'I <br /> Industrial Cable Tool Dia. of Well Excavation V' <br /> Domestic/private Drilled Dia. of Well Casing �� <br /> Domestic/public Driven Gauge of Casing [r <br /> Irrigation Gravel Pack Depth of Grout Seal d <br /> Cathodic Protection Rotary Type of Groat <br /> Disposal Other �� Other Information <br /> Geophysical Surface Seal Installed By: <br /> ' PUMP INSTALLATION: Contractor e mss. <br /> Type of Pump U H.P. / <br /> PUMP REPLACEMENT: j—/ State Work Done <br /> PUMP `i REPAIR: /7 State Work Done - <br /> ES•TRUCTION OF WELL: Well. Diameter Approximate Depth <br /> Describe Material and Procedure <br /> r <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 ofmy w on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT the well and notify them before putting..the. well in use.. The above <br /> informatio myowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO FI I E <br /> SIGNED TITL <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> - <br /> APPLICATION ACCEPTED BY C, �� DATE <br />" ADDITIONAL COMMENTS: /i L 77� - � d�� 1- <br /> PHASE II GROUT INS CTIO PHASE <br /> I FIN • NSPECTIO <br /> INSPECTION BY DATE /D INSPECTION BY - _�,,t� DATE f� <br /> E H.1426 Rev. 1-74 1-74 2M <br />