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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOR OFFICE•-HS • 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77_ KZJ " <br /> 77-100 -P <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby 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 Harrold venue , near, sca CENSUS TRACT <br /> Owner's Name Y Phone 524-5,9813 <br /> Address an.ta Teresa Drive Cit Modesto,Y M <br /> � , „ Calif_ <br /> Contractor's Name ALartin pump and -311-p-ply Co. License # 25.010.3 Phone 847--0394 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL I DEEPEN /_/ RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION /�/ PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK _50,r SEWER LINES 0i• PIT PRIVY �p�e <br /> SEWAGE DISPOSAL FIELD 5.Dt CESSPOOL/SEEPAGE PIT 33fte OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS O <br /> Industrial Cable Tool Dia. of Well Excavation I ft S ' <br /> X _ Domestic/private Drilled Dia, of Well Casing C_ 9jgir <br /> Domestic/public Driven Gauge of Casing 12 �y- - <br /> Irrigation Gravel Pack Depth of Grout Seal 501 <br /> Cathodic Protection X Rotary Type of Grout penton: <br /> Disposal Other Other Information <br /> f Geophysical Surface Seal Installed By: M.p.S. <br /> PUMP INSTALLATION: Contractor Suppt <br /> Type of Pump _a1 ib 3 eraj bl H•P• O <br /> PUMP REPLACEMENT,. / / State Work Done <br /> PUMP .REPAIR: � <br /> State Work Done . <br /> DES-tRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <br /> 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 /> i, ELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> in ation is true to the best g.,my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIG GROUTING AND I N. <br /> SIGNED TITLE s- <br /> DRAW <br /> PLOT P 'ON REVERSE SIDE) h <br /> FOR DE ARTMENT USE ONLY <br /> P _I <br /> APPLICAICEPTED B DATE f <br /> IV717 <br /> ADDITIONAL COMMENTS: <br /> P E I GR UT 1NSPECTIO PHASE III/FINAL INSPECTION <br /> INSPECTION B DATE INSPECTION BY DATE 7 <br /> �� <br />` E H 142 Rev. 1-74 3/76 2M I� U .�pr �, <br />