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FOl{,OFFICE USE: ' SAN JOAQUIN LOCAL, HEALTH DIS R T <br /> 1601 E. Hazelton Ave.. , ,Stockto f, <br /> Telephone: (204) 466-6 81 <br /> APPLICATION FOR WELL CONSTRUCTION R P <br /> T rmit o. 0. <br /> THIS PERMIT EXPIRES 1 YEAR FRO DA I S JAN IS 1978 <br /> 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 /> County Ordinance No. 1862 and 'the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION J 5(o3q, e0 Lt1 <br /> CENSUS TRACT <br /> Owner's Name • <br /> Phone <br /> Address S'® - <br /> City <br /> Contractor's Name -S � <br /> .License # `?-11Q�3Phone <br /> TYPE OF WORK (Check) : NEW WELL a7 DEEPEN '/—/_ - <br /> _ RECONDITION- J-7 DESTRUCTION /� <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /� _ <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> _Lao_-+ SEWER LINES _LLXa_ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL UBLI <br /> TYPE OF WELLPC DOMESTIC WE <br /> WELL <br /> LL <br /> Y <br /> Industrial CONSTRUCTION SPECIFICATIONS = <br /> _�� Cable Tool Dia, of Well Excavation <br /> Domestic/private 1r Drilled il <br /> Domestic/public -'-r4- Dia. of Well Casing +o 1 QQ <br /> Driven Gauge of Casing �• . <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection _ Rotary Type of Grout <br /> Geo — <br /> Disposal Other _ Other Information + <br /> Geophysical Surface Seal Installed B b CS <br /> G <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. . <br /> PUMP REPLACEMENT: , / / State Work Done <br /> PUMP :REPAIR: State Work Done <br />)ES•TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> L hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> ind the State of California pertaining to or regulating well "construction. Within FIFTEEN DAYS <br /> ifter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> TELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br />.reformation is true to the best of my knowledge and belief. I WILL CALL FO A GROUT INSPECTION <br /> RIOR TO GROUTING AND A FINAL INSPECTION. <br /> IGNED <br /> TITLE <br /> (DRAW PLOT .PLAN N VERSE SID ) <br /> RASE I FOR DEPART N US •ON Y <br /> PPLICATION ACCEPTED BY <br /> DDITIONAL COMMENTS: DATE 2=ZZg <br /> PHASE 11 GROUT INSPECTION f <br /> HSPEGTION BY PHASE III/FINAL INSPECTION <br /> DATE INSP " T N BY DATE <br /> E H 1426 Rev. 1-74 1. 77 <br />