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•� -gSAN JOA UIN LOCAL HEALTH DISTRICT <br /> •v <br /> V 1601 E. Hazelton Ave,," St.ockton, Calif. <br /> FORiQFFI� CE USE: ' <br /> Telephone: - A(209) 466-6781 33GP <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77- 336,4 <br /> THIS PERMIT EXPIRES I :YEAR FROM DATE ISSUED Date Issued <br /> (Complete In..Triplicate) <br /> Appliadtion is hereby made to the San Joaquin LOC <br /> al. f�ealth District for a permit to construct <br /> and/or install the work herein described. This application- ia ,made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations. the San Joaquin Local Health District. <br /> CENSUS TRACT <br /> JOB ADDRESS/LOCATION(, <br /> Phone <br /> Owner s s Name el. <br /> Address 6 t� ��. 5 . . .. ...... . - . City <br /> License # Phone, <br /> Contractor's Name e,5 Kl 3 y�� <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN /7 RECQNDITION / DESTRUCTION / <br /> PUMP INSTALLATION / PUmp REPAIR,/ / PUMP REPLACEMENT I j <br /> . Other L 7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PITC OTHER U <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavat`ion.:— - <br /> ._ -.T • •M Dia:^of�'W�11"Cg�ii�g -�""_:�. .. . <br /> Domestic/private -----'Drivend Gauge of Casing <br /> Dote eti c/public <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection , Rotary Type of -Grout <br /> Disposal Other . Other Information <br /> Geophysical .. . . . <br /> Surface Seal Installed By. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump le H.P. <br /> PUMP REPLACEMENT: L/ State Work Done <br /> PUMP :REPAIR: / - State Work Done <br /> ES;TRUCTION OF WELL: Well Diameter <br /> 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 /> and the State of California pertaining to or regulating well construction. <br /> 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. <br /> above <br /> information is true to the-best of- my knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. TITLE 4 �I �- <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> k PRASE I r DATE - <br /> APPLICATION ACCEPTED BY W2 a 2 <br /> ADDITIONAL COMMENTS:, Pte, I ��DATE <br /> INSPECTION,, <br /> PHASE I GROUT INSPECTION INSPECTION BY <br /> INSPECTION BY DATE <br /> 7C7---- <br /> 1-74 2M <br /> �i E H 1426 Rev. 1-74 <br />