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r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORIFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ]7-YL1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) -253- 340-31 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/orI' instalk the work herein described. This application is made in compliance with San Joaquin <br /> CouutyNOrdinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION East side of Lehmann Road; 1/2 mi, S of Linn*; CENSUS TRACT <br /> Owner° Name Jades Edwards in walnut orchard <br /> Phone 835--5982 <br /> Address , . 23544 S. Batmta Road, Tracy, CA 95376 City Tracy, CA <br /> Contractor's Name Western Well Drilling Co., Ltd. License # 25182 Phone 295-4332 <br /> 5 <br /> TYPE OF WORK (Check): NEW WELL 1-T DEEPEN /7 RECONDITION /7 DESTRUCTION f7 <br /> PUMP INSTALLATION /XX PUMP REPAIR /7 PUMP REPLACEMENT T7 <br /> Other /_7 <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 /> Domestic/public Driven Gauge of Casing -- , <br /> Irrigation Gravel Pack Depth of Grout Seal " <br /> - C athodicProtection Rotary Type of Grout <br /> Disposal. ' Other Other Information ...`� .� <br /> Geophysical ^" - <br /> Surface Seal Installed SX„ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. 60 - a <br /> PUMP REPLACEMENT: / IT State Work Done <br /> PUMP ,REPAIR: /^T 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 Districi _ <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 puttingthewell in .use.. The above <br /> information is true to the-best of my kno dge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR GROU FINAL INSPECTION. <br /> SIGNED TITLE President <br /> (DRA LAN ON REVERSE SIDE <br /> 'FOR DEPARTMENT USE ONLY <br /> PHASE I. <br /> APPLICATION ACCEPTED BY DATE 44°� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II1ZSINAL INSPEMION . <br /> INSPECTION BY DATE INSPECTION B . DATE <br /> t ~E H 1426 Rev. 1-74 / <br /> - 1-74 2M i <br />