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SAN JOAQUIN LOCAL HEALTH DISTRICT `R <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,�W-1Z 3jo <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,;/ .r�,4 <br /> (Complete In Triplicate)- <br /> Application is hereby made taIthe San Joaquin-Local Health District fora 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 Grant Line Road and MacArthur Drive, Tracy, CA CENSUS TRACT <br /> Owner's Name City. of Tracy _ Phone 209/835-2211 <br /> Address <br /> P.O. Box 1029, Tracy City Tracy <br /> [ San Jose License. # 25182 295-4332 <br /> Contractor's Name Western Well Drillingn�o. , Ltd., Phone <br /> 1 <br /> TYPE OF WORK (Check) : NEW WELL / /,: DEEPEN /_/ RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR fg / PUMP REPLACEMENT /� <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE :DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ' <br /> - V <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _ Cable Tool Dia. of Well Excavation <br /> Domestic/private 1 Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack ..Depth 61'-Grout-Seal <br /> Other Rotary Type of Grout <br /> Other ' Other Information <br /> , <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. , <br /> I <br /> PUMP REPLACEMENT: / / State Work Done <br /> 1 � <br /> PUMP REPAIR. / / State Work Done Tubeline Repair <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 tr a best of my knowledge and belief. <br /> i <br /> SIGNED TITLE President <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> T <br /> FOR DEPATTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _.,� �C�` DATECf— <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT IN PE_CTION PHAS II FI Al, INSPEC ION <br /> INSPECTION BY DATE - INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. yy <br /> E H 1426 7/72 1M J <br /> i�r �r <br />