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SAN JOAQUIN LOCAL HEALTU DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stocktoz., Calif. <br /> Telephone: (209) 466-6751 <br /> /APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No- 7z--51?3 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date I sued / q 7 L <br /> (Complete In Triplicate) <br /> Application is hereHy made to the San Joaquin Local Health District for 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 /> ;� o.t� ANew Hous+) on Acam o Rd. <br /> JOB ADDRESS/LOCATIOI pro,x Tenths of a bile East of KenefickCENSUS TRACT <br /> Owner's Name Lee R. Friedli A4 _ -- . G 7.7- , one 745-2687 <br /> Address 413 Sunset Drive, Galt, California City Galt, Calif <br /> Contractor's Name Shoup Well Drilling & Pumps License # 117291 Phone 368-3343 <br /> TYPE OF WORK (Check) : NEW WELL/19 DEEPEN / / RECONDITION /_-7 DESTRUCTION /_7 <br /> PUMP INSTALLATION /$,/ _PU1,1P REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ 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 ' fes-- <br /> . X Domestic/private Drilled Dia. of Well Casing A O <br /> Domestic/public Driven Gauge of Casing 12 <br /> Irrigation Gravel Pack Depth of Grout Seal 50 (h <br /> Other Rotary Type of Grout. chi Sk, <br /> Other Other Information ` <br /> PUMP INSTALLATION: Contractor Shoup P ups <br /> Type of Pump S hni .rsj hie H.P. 1 <br /> O <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ,pESTRUCTION 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,- rue to the best of my knowledge and belief. <br /> SIGNED TITLE Contractor <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I /` <br /> APPLICATION ACCEPTED BY �C DATE 6-- I a•70- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE /0 - __ -72 INSPECTION BY DATE /,9-49 -2� <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 6 -7 a 1 4/72 1M <br />