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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> --T 3jo-- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date, Issued / r <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-thee woorherein described. This application is made in compliance with San Joaquin <br /> CpUnty OrdinaAc No 71866l1and the Rules and Regulations of the San Joaquin Local Health District. <br />��4` � '' ` ' 8 mile north of Louisee- on East side <br /> B ADDRESS/LOCATION ,,rad down anuth w CENSUS TRACT <br /> fur 2 31_/3�fi <br /> Owner's Name _Dyayne Maa= i n Phone <br /> Address City Man _P _a <br /> Contractor's Name Stanislaus Pump & Machinery Corp. License # A290355 Phone 522-9092 <br /> IV <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /—T DESTRUCTION /-7 <br /> PUMP INSTALLATION/x/ PUMP REPAIR / / PUMP REPLACEMENT /) <br /> Other /-7 <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 /> x 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 S anjsl us Pimp & Marhinexy rlo„•p, <br /> Type of Pump Johnston Turbine T H.P. 40 <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION 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 GR TING AND IN INSPECTION. This is ready for i .pp ctio <br /> SIGNED Tffff <br /> DRAW P-tPLAN ON REVERSE SIDE) <br /> F)o DEP TMENT USE ONLY <br /> PHASE I /' - <br /> , zh. <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II/FI INSPECT N <br /> INSPECTION BY DATE INSPECTION BY ATE IVa <br /> r� <br /> E H 1426 Rev. 1-74 3 76 2m <br />