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V+ V1601 <br /> SAN JOAQUIN LOCAL,HEALTH DISTRICT <br /> FOB OFFICE USE: E. Hazelton Ave -','.Stockton, Calif. <br /> Telephone: 1(2;9) 4666781 <br /> APPLICATION FOR WELL CONSTRUCTIO <br /> N OR PUMP PERMIT Permit No. 72L-/{ z&l <br /> THIS- PERMIT'EXPIRES:l.YEAR -FROM DATE ISSUED Date Issued AL -7 <br /> - (Complete,.In.Triplicate) <br /> ct <br /> Applicdtion is hereby made to the San Joaquin Local:,Health. .District for a pera�t to with <br /> San Jo <br /> and/or install the work herein described4-This application is made in compliance with San Joaquin: <br /> County Ordinance No. 1862 and_the*Rules and Regulatians;:Of .the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION °' �,�...�..�.�, „��ptiV/P CENSUS TRACT Del <br /> w`A Phone - ,3 <br /> ,17-40 <br /> i Owner's Name' �' if _ <br /> lfµ � � .w WOODS WELL DRILLING City <br /> Address� � 11944 Simmerhorn Road <br /> Galt,California 95632 <br /> Contractor's Name . �' - LicensePhone � y l <br /> .-�.. <br /> TYPE OF.WORK (Check): NEW WELL DEEPEN '/7 RECONDITION /7 DESTRUCTION r1' <br /> PUMP INSTALLATION J. . PUMP,_REPAIR / PUMP REPLACEMENT rT <br /> Other S7 <br /> 7; <br /> DISTANCE TO NEAREST: [SEPTIC TANK »D SEWER LINES PTT PRIVY Z <br /> ! SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 6 <br /> I -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 /> i Y-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 '1A&-' <br /> Disposal ! Other Other Information <br /> Geophysical. Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor e5 <br /> ° Type of Pump 5''U.6 ... H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> ,...PUMP-'.REPA1-R:- �L7T---;-State�Work-Done'. <br /> 4EiiRUCTION OF WELL: ' Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to compXy with all .laws and regulations of the San Joaquin Local Health District <br /> t 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 4 <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 GROUTING,AND A,F1Na INSPECTION. <br /> SIGNED 4 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> ,.FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED'BY . DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II ROUT INSPECTION PHASE ITT/F NALNSPECTTON� <br /> INSPECTION BY DATE z INSPECTION BY DATE <br /> 1 <br /> 1-74 2M <br /> E R 1426 Rev. 1-74 <br />