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- SAN JOAQUIN LOCAL HEALTH DISTRICT <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. <br /> f <br /> THIS PERMIT EXPIRES "1 YEAR FROM DATE ISSUED Date Issuedd <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 /> E County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> # JOB ADDRESS/LOCATION 22484 E. MaripQgg Road- Psca nn, Ca1i'f_ CENSUS TRACT <br /> Owner's Name 'Phone 838-26$8 <br /> Address 2248 E_ Ma-riipsa-RnnA_ City Esc&" Ca_ <br /> Contractor's NameStanisl-ausarp- License # A2� Phone 522-9027 <br /> h � <br /> TYPE OF WORK (Check) : `NEW WELL/ / DEEPEN / / RECONDITION /_/ DESTRUCTION <br /> F PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT fes_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY y <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 /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> x 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 /> PUMP INSTALLATION: Contractor Stanislaus Pump & Machinp3z Corp_ <br /> Type of Pump Johnston Turbine H.P. 25 <br /> PUMP REPLACEMENT: /_X/ State Work Done <br /> Raacs 5-14F_srff,h_ 25 up ....��...� <br /> PUMP.:.REPAIR: State" Work- Done <br /> AES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure i. <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 GRO ING AND AYZNAL INSPECTION. This is ready for inspect' n. . <br /> SIGNED TITLE )�' <br /> DRAW.PL- T PLAN ON REVERSE S ITE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ _ { DATE 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II /FINAL INSPECTION <br /> 1 INSPECTION BY DATE �, - INSPECTION BY ATE <br /> 1 Y <br /> 1426 Rev. 1-74 .. . , <br /> 3/76 2M <br />