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`]fir! SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 _ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT » Permit No. -S/• Id <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE IS3t6 Date Issued j <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or instar, 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 22562 Bbul. i'.d. 74Lac l ca. f CENSUS TRACT <br /> Owner's Name Don ft: Co4e. Phone -835-6508 <br /> Address P.0. Bax 326. 7 J�.,�Aac.�.� <br /> City kl •Ca.. <br /> Contractor's Name Heruz &ZD4. tue t k&LtLLW, Com. _7nc.•. License ; 776322 Phone <br /> �?-JUU 0. PurL(r Rd. lea e4to, sx. 95350 <br /> TYPE OF WORK (Check): NEW WELL /37 DEEPEN17 RECONDITION DESTRUCTION /7: <br /> PUMP INSTALLATION/ /PUMP REPAIR-/-7—PUMP REPLACEMENT /7 <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 7i" <br /> X Domestic/private" Drilled '" y� Dia. of Well Casing " i) c <br /> f - Domestic/public Driven v Gauge of Casing -0a),L <br /> Irrigation Gravel Pack Depth of Grout Seal 50' <br /> Cathodic Protection X. Rotary Type of Grout <br /> Disposal. Other Other Information ' • Stab .GL!,•Owaelt <br /> Geophysical' Surface Seal Installed 'B cUi [ 1 e& <br /> y PUMP INSTALLATION: Contractor <br /> Type of Pump y'H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> it ,. <br /> t PUMP '.REPAIR: I I State Work Done <br /> _ <br /> UES;TRUCTION OF WELL: Weil Diameter <br /> .Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of 'the-SM Joaquin Local Health District <br /> And the State of California pertaining to or regulating weirconstruction.. Within FIFTEEN DAYS <br /> I .after completion of my work on a new well, I will furnish the San Joaquin Local Health Districta <br /> WELL DRILLERS REPORT of the well and notify them before putting..the..well. in .use.... The above <br />'. information is true to •best ..of my.-knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GRO ING M01A F AL INSPECTION. . <br /> SIGNED TITLE OwnevL <br /> Don e (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 'r 7 <br /> ADDITIONAL COMMENTS: <br />` PHASE ROUT INSPECTION F II NAL INSPECTION <br /> INSPECTION BY DAT INSPECTION BY DATE <br /> 4 <br /> E <br /> H41426 <br /> Rev. 1-74 U7 2NI <br />