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SAN JOAQUIN LOCAL HEALTH DISTRICT 1 <br /> FOBrOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. # <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-oW7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued &---'.)-77 <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 /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 3 19S0 .S• C'K��s l"6j 4,,� 25 3 - 2s'o_,?c) <br /> JOB ADDRESS/LOCATION 114 Mi. S of Durham Ferry Rd; 113 Mi. E of Chrisman CENSUS TRACT <br /> Owner's Name Ruiz Bros. Phone 209/835-1453 <br /> Address 31313 S. Bird Road City Tracy, CA <br /> Contractor's Name Western Well Drilling Co. , Ltd. License # 25182 Phone 295-4332 <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN /_7 RECONDITION /7 DESTRUCTION f7 <br /> PUMP INSTALLATION /X} PUMP REPAIR 17 PUMP REPLACEMENT f7• <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ; w <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER po <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL — PUBLIC DOMESTIC WELL (� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS C' <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> 'Trrlga[fo _' Gravel Pack Depth of .Grout Seal n <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical - - Surface Seal Installed By: h <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump Vertical H.P. 10 <br /> d <br /> PUMP REPLACEMENT: / / State Work Done � <br /> PUMP .REPAIR: /_' State Work Done ' <br /> ES•TRUCTION 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., <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 knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR GROUTING AND A FINAL INSPE N. <br /> SIGNED TITLE President <br /> �dmW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: - <br /> PHASE II GROUT INSPECTION PHA IIIAL INSPECTION ' <br /> INSPECTION BY DATE INSPECTION BY DAT / <br /> E H 1426 Rev. 1-74 i_7A 7M T <br />