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4r. SAN JOAQUIN LOCAL"HEALTH DIST I" Nuc <br /> FOA+rOFFICE USE: 1601 E. Hazelton Ave. , 'Stop <br /> � ���ion <br /> Telephone: (209) 466�- 9 <br /> APPLICATION FOR WELL CONSTRUCTA OR PUMP E�40rmit No, 77-/3 p/a <br /> THIS PERMIT EXPIRES 1 YEARrtFRO DACE IS � ate Issued 1 27 <br /> r (Complete In TripID <br /> Application is hereby made to the San Joaquin Local Hea ' for a permit to construct <br /> and/or install the work herein described. This applicatis 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 S , CENSUS TRACT <br /> Owner's Name STA IV& Phone 3 <br /> Address <br /> City <br /> Contractor's Name 2f..... License lia?Zhto Phone <br /> TYPE OF WORK (Check) : NEW WELL/_7 DEEPEN '/? RECONDITION /? DESTRUCTION (7 <br /> / Y .. <br /> PUMP INSTALLATION { PUMP REPAIR J� PUMP REPLACEMENT <br /> Other E7 i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ;PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY EINE -`PRIVATE DOMESTIC WELD,: PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL .CONSTRUCTION SPECIFICATIONS \ <br /> Industrial Cable Tool w ` 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 Grant _ <br /> Disposal ' Other Other Information <br /> Geophysical Surface Seal "installed Bj: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pu <br /> mp A.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP '.REPAIR: ` L_7 _.State Work Done - w -- <br /> ES;TRUCTION OF WELL: Well Diameter K J Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin'Local Aealth 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 CA1j, FO -A GROUT INSPECTION <br /> PRIOR TO GROU NG AND A F AL NSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE)& <br /> ,w <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> i <br /> APPLICATION ACCEPTED BY DATE 7 i <br /> ADDITIONAL COMMENTS: <br /> PHASEUlfGROUT IN ECTION PHAS III AL <br /> INSPECTION BY DATE INSPECTION- BY DATE <br /> i E H 1426 Rev. 1-74 ,. <br />