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by � <br /> + ,,,J SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOR OFFICE USE: ITIA 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. /O4J <br /> 77-1 d o-5 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued g-2--7 <br /> (Complete In Triplicate) <br /> Application is here 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 2'r7 CENSUS TRACT <br /> Owner's Name i Tomm Edwards -- - - - Phone 847-.1606, <br /> i Address 6545 East River Road- city nakdale, Calif. <br /> Contractor's Name Margin PuM and, Snp-Ply COi_ _ _ License # 25010 Phone847-0394 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL -7 DEEPEN '/ / RECONDITION / / DESTRUCTION /� <br /> PUMP INSTALLATION /X./ PUMP REPAIR / / - PUMP REPLACEMENT / <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK riot_ SEWER LINES 501 PIT PRIVY nn:n e <br /> SEWAGE DISPOSAL FIELD r CESSPOOL/SEEPAGE PIT n©ne OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> E Industrial Cable Tool ;Dia-. of- Well Excavation 17. , <br /> X Domestic/private Drilled Dia, of .Well Casing $;F+ <br /> r Domestic/public Driven Gauge of. Casing 12 - <br /> l-rrigation _Gravel Pack- Depth of Grout Seal SQA c� <br /> 4 Cathodic Protection Z Rotary Type .of Grout geil$pnite <br /> Disposal Other "'Other Information <br /> Geophysical Surface Seal Installed By: <br /> I!. P _INSTALLATION: Contractor a tin uCO. <br /> —� Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done _ <br /> DE=- <br /> tTRUCTION OF WELL: Well Diameter.- Approximate Depth <br /> E Describe Material and Procedure <br />� .1y <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 ' k8 Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> 'aEL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> info tion is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR GROUTING AN A P ION. <br /> SIGNED TITLE U � <br /> DRAW PVOV PLAN 'ON REVERSE SIDE ; <br /> OR DEPARTMEN ONLY <br />• F I � d <br /> APPLICATION ACCEPTED B �ol . DATE O Z <br /> ADDITIONAL COMMENTS <br /> PHASE II GROUT INSPECTION PHASE II/FINAL INSPECTION <br /> INSPECTION BY DATE - ; ' INSPECTION BY DATE /- 7�f- 77 <br /> - /✓o g.ra v.7 C 1 �s�'� r I 3/76 eo <br /> E H 1426 Rev. 1-74 � ,� tri rrT /i��/9. L�✓�4 „� . f/As f <br />