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SAN JOAQUIN LOCAL HEALTH DIST C( t1, A <br /> f <br /> FORfOFFICE USE: 1601 E. Hazelton Ave., Stoc�t�� � <br /> Telephone: (209) 466`=b�81 <br /> APPLICATION FOR WELL CONSTRUCT OR PUMP P, T ermit No. 77- ),3 J° <br /> / THIS PERMIT EXPIRES I YEAR FR9M � ISS , D ate Issued <br /> (Complete In Tri Beate <br /> � Am t? . , , ) <br /> AppliedtionTis hereby made to the San Joaquin Local HeA th Dlskrict for a permit to construct <br /> L �� <br /> and/or install. the work herein described. This applicationtis made in compliance with San Joaquin <br /> County Ordinance No. 1862 an8 the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION f?jiletj CENSUS TRACT <br /> Owner's Name N�/11F�'V ��p - Phone a� <br /> Address Y _ city <br /> Contractor's Name T License /V Phone <br /> TYPE.OF WORK (Check): NEW WELL 17 DEEPEN-'/-7 RECONDITION /7 DESTRUCTION f7 <br /> PUMP INSTALLATION PUMP .REPAIR j / PUMP REPLACEMENT <br /> Other C.L 4 &&/ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER- LINES PIT PRIVY <br /> SEWAGE4DISFOSAL FIELD ;CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL RA <br /> INTENDED USE TYPE OF WELL ' CONSTRUCTION SPECIFICATIONS <br /> Industrial l Cable Tool Dia. of Well Excavation <br /> Domeitic%private- Drilled Dia. of Well Casing <br /> Domestic/public _ -Driven # Gaugeyof. Casig. <br /> Irrigation Gravel Pack 4 Depth of Grout Seal <br /> Cathodic Protection Rotary ' Type of Grout <br /> Disposal _ Other Other Information <br /> Geophysical r * , Surface Seal,-:Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type iaf Pump H.P. <br /> PUMP REPLACEMENT: State Work Done Frnp�,-� �,v,c �.n1.4 <br /> PUMP79EPAIR: <br /> 2ESTRUCTION OF WELL: Well Diameter �.s Approximate Depth <br /> '- Describe Material and .Procedure <br /> I hereby agree to comply with all laws and regulations of the San Jnhquin 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 TO GRfl NG AND A4FIN4 INSPECTION.." <br /> SIGNED f TITLE = -} <br /> (DRAW PLQT ,PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED -BY DATE <br /> ADDITIONAL COMMENTS: I <br /> PHASE ATAGROUT INSPECTION PHAI AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> ,� H�'14.26 :. _Rev. 1-74. 1-74�2M y <br />