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T a'4I" � jd� `�SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> _ II1) <br /> FOR OFFICE UEd '), <br /> 1601 E. Hazelton Ave. , Stockton, Calif. f <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELT, CONSTRUCTION OR PUMP PERMIT Permit No. 77� S S 7bU <br /> 7- S9� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued s - 7 <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 apd the ulep and Regulations of the San Joaquin Local Health District. <br /> aDD9S ' C�>" 7-01ct .24 Mi. East Wa1Z Road CENSUS TRACT <br /> JOBS/LOCATION 150 South <br /> Owner's Name Mrs. White Phone <br /> 4 <br /> Address 20!90 E. Comstock Road, Linden, Cai_if: 95236 City <br /> I'urviance i1ri1.1-ers '.O.Eox 64,Lindeh';Ca0,_1 f•License # 240107 Phone 931-4468 <br /> t <br /> Contractors Name , <br /> r <br /> 7 <br /> -DESTRUCTION_../? ._. i <br /> TYPE OF WORK (Check) :- <br /> NEW x7- -DEEPEN-'I ' ,RECONDITION--I I, ;, - <br /> ---..-___ —�..,..-,.-.-P ip INSTALLAT•ION-//---PUMP- RERAIR /-I PUMP REPLACEMENT-�I - <br /> Others/''/ <br /> DISTANCE TO NEAREST: SEPTIC TANK 75' SEWER LINES 751 PIT PRIVY <br /> SEWAGE DISPOSAL-FIELD-_ .. , CESSPOOL/SEEPAGE PIT OTHER <br /> 2 PROPERTY LINE --PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL—� <br /> INTENDED USE TYPE OF WELL :; , CONSTRUCTION SPECIFICATIONS <br /> ble'Tool'�, ' ''Dia. of Well. Excavation all <br /> Industrial x Ca1 <br /> X Domestic/private • r Drilled Dia.-of Well Casing 8" <br /> t.. <br /> Domestic/public Driven"`"- -� ' Gauge' 'o€ -Casing <br /> ' Gravel Pack De th:of Grout Seal 50' <br /> irrigation p <br /> Cathodic Protection Rotary Type of Grout Neet Cement <br /> — Other Other Information f - <br /> -Disposal <br /> Geophys ic'a1 --_-,�....._ Surf ate Seal Installed By: <br /> T . <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. l <br /> PUMP REPLACEMENT: [ / State Work Done Replace Existing Customer Pump - <br /> PUMP .REPAIR: /: / State Work Done <br /> _ —�.... <br /> DES-TRUCTION 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 FOR A GROUT INSPECTION <br /> PRIOR TO GROUTI G A FINAL INSPECTION. Partner <br /> SIGNED TITLE <br /> DRAW PLT PLAN 'ON RE ERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS- <br /> PHAS II GROU INSPECTIO , P E I/ NAL INSPECTIO <br /> INSPECTION BY DATE 'j INSPECTION BY DATE rJ <br /> 4 , <br /> 3/76. 2M <br /> G E H 1426 Rev. 1-74 -� - <br />