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- - "� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. i <br /> Telephone: (209) 466-6781 <br /> -APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued a'� <br /> (Complete In Triplicate) <br /> Application is reby made to the Sail 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 22298 S. Henry . LL .mi. So. Hall. Road — CENSUS TRACT <br /> • P <br /> Owner's Name _ john witoke - - -- Phone 529-9644. --- + <br /> Address _ 22298 S. Henry _ City <br /> Psca3 on <br /> Contractor's Name Stanislaus Pump License # A290355 Phone _ 522-2027 <br /> i <br /> TYPE OF WORK (Check):­NEW-WE _—% / yDEEPEN / -/ ' -RECONDITION /_/ 'DESTRUCTION /F ` _ <br /> PUMP- INSTALLATION / PUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ; <br /> 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 /> X 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 <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> i <br /> PUMP INSTALLATION: Contractor Stanislaus Pum <br /> Type of Pump ,-Myers Submexsib a ---- H.P. 1 <br /> PUMP REPLACEMENT: / / State Work Done <br /> m <br /> PUMP. REPAIR: a :J_/ -State Work Done <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 true to the-best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GAPUTING FINAL INSPECTION. This is ready for inspection. <br /> SIGNED TITLEJA <br /> DRAW.PL T PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIO PHASE I I/FIN& INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DAT ` 7 <br /> E H 1426 Rev. 1-74 c.. e-`7— 77 SNW3176 2M <br />