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_ . / JOAQUIN LOCAL. HEALTH DIS <br /> FOR OFFICE USE: ' V 160. Hazelton Ave. , ,Stockto U <br /> Telephone : (209) 466-6 81 <br /> APPLICATION FOR WELL CONSTRUCTION R P T., rmit o. �_ <br /> JAN 16 1978 <br /> THIS PERMIT EXPIRES 1 YEAR FRO DA I S Date Issued <br /> (Complete In Triplicate) <br /> Application is Aereby 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 Joaquic <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health Distr]ct. <br /> JOB ADDRESS/LOCATION 15 63,f, Su S,f e i- n ea o A uc . CENSUS TRACT <br /> Owner's Name Rr��,('1' er Phone <br /> Address �5h3�( 5t S f P i n k City ' ]'�r'/.Llt)n <br /> Contractor's Name �< hGH �f I��If� 'D• ISP.. License 11L3Phone <br /> -- <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN/ / RECONDITION_/ / DESTRUCTION /-J <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-T <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK _La()L+ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL — PUBLIC DOMESTIC WELL — <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS S <br /> Industrial Cable Tool Dia. of Well Excavation <br /> j% Domestic/privateDrilled Dia. of Well Casing ' <br /> —`t- Domestic/public Driven Gauge of Casing I 1V <br /> Irrigation Gravel Pack Depth of Grout Seal ,rjL <br /> Cathodic Protection Rotary Type of Groutr�P 11 t'Un i <br /> Disposal Other Other Information `Slab by a!ner- CS <br /> Geophysical Surface Seal Installed Bv: C <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 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. 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 FO A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN N VERSE SID ) <br /> FOR DEPART N US ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPT6 BY _ DATE % <br />