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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r7O . OFFICE USE: V 601 E. Hazelton Ave. , Stockton, Calif. 7 s--"?1-?)p <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued "- -7,5- <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 87-28- N- 1)uncan Read CENSUS TRACT <br /> Owner's Name L=dQjai .- ' .' -- Phone <br /> a. <br /> Address Calif, City <br /> Contractor's Name Ross Puryjanop,tD-r.i l l iae License # 180532 Phone 887-,3480 <br /> TYPE OF WORK (Check) : NEW WELL I DEEPEN '/ / RECONDITION I / DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT Ir7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK 1251 SEWER LINES 1251 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial x Cable Tool Dia, of Well Excavation gt? <br /> Domestic/private Drilled Dia. of Well Casing grr _ <br /> Domestic/public Driven Gauge of Casing - - 10 ga <br /> Irrigation Gravel Pack Depth of Grout Seal 60' <br /> Other Rotary Type of Grout Neet Cement <br /> Other Other Information <br /> PLWI INSTALLATION: ` Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> .DFRTRUCTION 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 PORT the well and notify them before putting the well in use. The above <br /> informati is t ue to he best of my knowledge and belief. <br /> SIGNED - C-C�� TITLE Owner <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> F R DEPARTMENT USE ONLY <br /> PHASE I _ <br /> APPLICATION ACCEPTED BYE 1 DATE A- 75 <br /> ADDITIONAL COUNTS: <br /> PHA E OUT INSPECTION PHASF9 TAIIFIWAL INSPECTION <br /> INSPECTION BY ATE - 75 INSPECTION BY <br /> CALL FOR A GROUT INSPEC ON PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 5/731M <br />