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r. <br /> �p � <br /> SAN 30AQUIN �Z�}CAL.HEALT�fi DISTRICT ' <br /> FOR OFFICE USE: V/ <br /> 160 .:.rE....�Hanel"ton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 73-//S <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> j (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 /> 30B ADDRESS/LOCATION One-fourth mile North of Graves on Jacktone CENSUS TRACT <br /> Owner's Name James E. Rasband, Ni.D. Phone "2965 <br />! <br /> 373 <br /> Address 941 Sand :Dune Rd. Pebble Beach Calif. 93953 City <br /> Contractor's Name Hennings{ Bros. Drilling Co.,_ KnC. License # 116322 Phone 522-56 3 <br /> 250p_X,_:Rwih1e Rd. KodestL)j Cal, <br /> TYPE OF WORK (Check): NEW WELL /R7. DEEPEN /_/ RECONDITION /_7 DESTRUCTION 1-7 <br /> PUMP INSTALLATION / I PUMP REPAIR / / PUMP REPLACEMENT /_7 , <br /> Other '/ / <br /> DISTANCE TO NEAREST: SEPTICTANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED `USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial � Cable Tool Dia, of Well Excavation 22" � <br /> Domestic/private Drilled Dia. of Well Casing _ 146' <br /> Domestic/public Driven Gauge of Casing r 3/16"___-_-- - <br /> x Irrigation_ . X. Gravel Pack Depth of Grout Seal <br /> Other ` x Rotary ' Type of Grout <br /> � ., Other Other Information <br /> PUMP INSTALLATION: '" S <br /> Contractor <br /> Type of Pump H.P. <br /> i <br /> PUMP REPLACEMENT: / / State Work Done �. <br /> PUMP REPAIR: / / State Work Done P No r I <br /> ,ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agreepto 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 th best, of my tcnowledge and belief. <br /> k n <br /> rSIGNED TITLE <br /> (DRAWreLYT ON REVERSE SIDE <br /> DEPARTMENT USE ONLY <br /> PHASE I ` r ---- <br /> APPLICATION ACCEPTED BY DATE �.� -" <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA II ,FINAL INSPECTION <br /> „ INSPECTION BY BATE INSPECTION BY DATE .104929 7z <br /> CALL FOR A GROUT INSPECTION PRIOR- TO GROUTING AND FINAL INSPECTION— <br /> E H 14267/72 1M 15 <br /> R } F' <br />