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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE _OFFICE USE; /1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : '(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77 J g-S10 <br /> I <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 pp 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 16244 S. Cottage Ave . CENSUS TRACT <br /> Owner's 'Name Marie Nunes Phone 823-522$ <br /> Address P. 0. Box 888 City Manteca <br /> Contractor's Name I. J. . Larsen Pumps , Inc . License. # 276660 Phone 529-2020 <br /> 509 TulliE R CA 99350 .i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN / / RECONDITION /7 DESTRUCTION /_7 - <br /> PUMP INSTALLATION/ / PUMP REPAIR %/ (PUMP REPLACEMENT �c-7 <br /> Other / / E <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/privateDrilled -- - - - - <br /> �-Dia. of Well Casing <br /> Domestic/public ' Driven. Gauge of Casing <br /> Irrigation ;,r Gravel Pack Depth of Grout Seal <br /> t Cathodic Protection -Rotary Type of Grout, <br /> Disposal Other Other Information ' -- <br /> Geophysical ISurface Seal Installed By: <br /> i <br /> PUMP INSTALLATION: <br /> Contractor <br /> Type of Pump, H.P. <br /> PUMP REPLACEMENT: . / State Work Done Pull & install neer I HP subm <br /> REPAIR:. <br /> .:;- // $:taterWork .Done <br /> DESTRUCTION OF WELL: Well Diameter - - -- - <br /> Approximate Depth <br /> Describe Material and Procedure s <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District l <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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT7 PLOTPLAN ON RE FRSE SIDE) ,. 7U <br /> '► <br /> PHASE I OR BEP NT UV ONLY <br /> APPLICATION ACCEPTED BY DATE ( �/ <br /> ADDITIONAL COMMENT <br /> PHASE II GROUT INSPECT N PHAS III FINAL, NSPECTION <br /> INSPECTION BY DATE INSPECTION BY m,1VATE '7 <br /> E H 1426 Rev. 1-74 p SAS/.r }�✓� 3/76 2M <br />