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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR?OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APF1,rICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77_ O, <br /> p <br /> 7// H <br /> TIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 2- 2- 77 <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 North side Durham Ferry Rd; 1 mi. E. Koster Rd; CENSUS TRACT <br /> comer of Section 1 ..�. - '-- <br /> Owner's Name Wal&pr Williamson _,- Phone 222t.835-3146 <br /> Address 501 W Durham Ferry Road City Traey <br /> Contractor's Name Western Well Drilling Co., Ltd. License # 25182 _ Phone 225-4D2 <br /> TYPE OF WORK (Check): NEW WELL ,/_7 DEEPEN -/-7 RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION / J PUMP REPAIR /A PUMP REPLACEMENT %f <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 <br /> Industrial Cable Tool 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 Grout <br /> Disposal Other .____� Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP-.REPAIR: State Work Done <br /> ES�TRUCTION OY'WELLc -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 notif them before putting the..well in.use.. The above <br /> informat on is true to the-best-of my know ge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR ROU FINAL INSPECTION. <br /> SIGNE TITLE Vice President 1./31/77 <br /> (DRAW LOT)PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE kz <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P II INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE x <br /> 1 E H 1426 Rev. 1-74 1-74 2M <br />