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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. 7;7ng?A1o <br /> a <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 4t .i -77 <br /> (CompleteInTriplicate) <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 CENSUS TRACT <br /> Owner's Name Psi Pter Groexiveid - -- Phone 838-7102 <br /> Address 22871B. Mariposa Fse�a.l-nn ___ City <br /> Contractor's Name r. License #200774- Phone <br /> i <br /> TYPE OF WORK (Check) . NEW WELL J / DEEPEN '/ / RECONDITION J / DESTRUCTION /-7 <br /> - s - "P IMP INSTALL'AT 013 ` ( PTJFII' "R PAIR''j % PUMP'REPLACEMENT j? - <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 /> Domestic/private Drilled Dia.. of Well. Casing <br /> 'Driven�"_`��r"Gauge <br /> XX Irrigation Gravel Pack Depth of Grout Seal \ <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information ' <br /> i <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor J falter G'. Noack <br /> Type of Pump Turbine H.P. 30 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: J 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 w9 on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT the well and notify them before putting the well in use. The above <br /> information is t u to the best of y knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU NS I <br /> SIGNED TITLE <br /> DRA <br /> 'OT PLAN 'ON REVERSE 5ID <br /> DEP MENT USE ONLY . <br /> ai <br /> PHASE I <br /> APPLICATION ACCEPTI V4 L DATE 3-2-3 <br /> ADDITIONAL COMMENTS: <br /> K� PHASE II ROUT INSPECTION PHAS I I/ AL SPECTIO <br /> TrNSPECTION BY " DATE INSPECTION $Y DATE <br /> 3/76 2M <br /> �!E H 1426 Rev. 1-74 <br />