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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> _F06 OFFICE L'SE: L 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR Wr_LL CONSTRUCTION OR PUMP PERMIT Permit No. 2-.`7*a <br /> THIS PERMIT EXPIRES 1 YEAR FROH DATE ISSUED Date Issued -4--la-74 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for o pant to construct <br /> and/or install the work herein described. This application is sada in esplianee with San Joaquin <br /> li <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION - HWX 1 O pWSUS a'AACT <br /> ST SIZE Phone 818_7'•+6? <br /> Owner's Name hQBi: <br /> Address S. VAN ALLEN RD, City MANTFC'A <br /> Contractor's Name FEN',1T_` SS '.?ROS— DETT.T.TN0 00. .I:1C. License ! 29081 I Phone52?-1 011 <br /> ,,50o ',' DUMLBB An _ MOD• <br /> :YPE OF WORK (Check): p INSTALLATION -]EW WELL ET DEEPEN /?`V RERECOPAIRIL -7PUMP REPLA ELEMENT L7 <br /> L <br /> Other /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK L2,9171 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ur//-i0 <br /> PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOlM-STI(' WELL —. V <br /> INTENDED USE TYPE OF WELL CONSTRUC2'ION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of ell Excavation 1111 <br /> _ X _ Domestic/private Drilled Dia. of Well Casing 6_5181' <br /> Domestic/public Driven Gauge of Casing iP r.A <br /> Irrigation Gravel Pack Depth of Grout Seal 5()1 <br /> Cathodic Protection X _ Rotary Type of Grout Fpn tnnit p <br /> Disposal Other Other Infnrsation z].a.ha`hir nwnpr <br /> Geophysical Surface Seal Installed 8': d rillpr <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: L/ State Work Done <br /> PUMP .REPAIR: /_7 State Work Done <br /> ES TRUCTION OF ) Well Diameter ApproAmate Depth <br /> Describe Material and Procedure — f <br /> I hereby agree to coaply 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 FOP. A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED "1 G" `:': Di;ILLING CO. INC. BY TITLE-MaS '('• <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> DEPARTMENT USE ONLY / <br />