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SAN JOAQUIN LOCAL."AEALTH DISTRICT <br /> NOE(OFFICE USE: 1601 E. Hazelton Ave. , ' 'tockton, Calif. 3 <br /> Telephone: (209)- 466=6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�8Lr� <br /> - THIS =PERMIT EXPIRES" I"YEAR'fJ�R4M DATE ISSUED- Date Issued/D�� J� <br /> -(Complete,In Triplicate) <br /> Application is hereby made to the San Joaquin �Lar.al` IIealth` District for a permit to construct <br /> 1 and/or.install .the work herein described: ,- Thi's application .is.made in compliance with San Joaquin <br /> Countq'YOrdinanceNo., 1862 and the Rules .and-Regulations".of.jthe San Joaquin Local Health District. <br /> z CENSUS TRACT <br /> JOB ADDRESS./LOCATION � OKEF_ :­-- yG! ( 6 7 - Mark <br /> Owner°s Name W'91 G T Phone TTT <br /> City ' At <br /> Address--`--!/q2- - N' <br /> Contractor's. Name 11� L: License 4 ��' hone. f <br /> c Ifs- M 4 • <br /> TYPE OF WORK {Check): NEW WELL DEEPEN ./? RECONDITION / _,,,.,DESTRUCTYON <br /> PUMP INSTALLATION PUMP -REPAIR f� PUMP REP -7 <br /> Other /_7 ' <br /> DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINES PIT PRIVY G <br /> SEWAGE DISPOSAL FIELD (� ; . CESSPOOL/SEEP.AGE PIT OTHER <br /> PROPERTY LINE 4;_PRIVATE DOM3�STIC WELL =_ PUBLIC DOMESTIC WELL <br /> k INTENDED USES TYPE OF WELL �, CONSTRUCTION SPECIFICATIONS <br /> Industrial fable Tool ,_,, Dia. of Well Excavation - / <br /> ---Domestic/private Drilled 'Dia.--of Well Casing <br /> Domestic/public Driven Gauge of Casing ` <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic. Protection , . ; Rotary Type of Grout <br /> Disposal -.- Other 71 Other Information t <br /> Geophysical Sur€ace Seal Installed B_ :. <br /> PUMP INSTALLATION: Contractor .Vw v` <br /> H.P. «, <br /> Tyrie :of Pump —s - - - - <br /> ; <br /> PUMP REPLACEMENT: / / State Work,Done <br /> PUMP 'REPAIR: �-7 State Work`Done ' <br /> pESRUCTION OF WELL; Well Diameter - — —" Approximate Depth <br /> Describe Material .and Piocedute <br /> I hereby agree to comply with all laws and. regglations of the San Joaquin Local Health District <br /> i and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new wel3 ,,I will fur ish 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 TO GROYIENG,AND A FINAL INSPECT ` <br /> 5IGNE TITLE <br /> RAW PLOT PLAN ON :REVERSE SIDE <br /> FOR_DEPARTMENT-USE-.ONLY <br /> PHASE-I` <br /> APPLICATION ACCEPTED BY <br /> It. ADDITIONAL COMMENTS: <br /> PHA I G UT INSPECTION PRASE iI /FINAL INSPECTION <br /> INSPECTION BY DATE �" INSPECTION BY DATE <br /> t 44 1-74 2m <br /> 1 E H 1426Rev. 1-74 j0//� 7 �doC <br />