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SAN JOA.QUIN$.&WAIS HEALTH DISTRICT <br /> FaE OFFICE I1SE � �601 E. Hazelton Ave. , Stockton, Calif. <br /> 7 <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,6 <br /> 4r <br /> THIS PER�IZT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �� 2 <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. 1852 and the Rules and Regulations of the San Joaquin Local. Health District. <br /> ,TOB ADDRESS/LOCATION Lathrop Rd...M1 Nest gf Cottage-Rdaa SoUt Cottage— CENSUS TRACT <br /> 'side <br /> Owner's Name � Pho � Aq-P- ,4 <br /> Address 7,272 B..*J.LathrQD,-.Rd, City .� atc-A <br /> µ License �L Phone 522 1O <br /> - <br /> Contractor's Name - 2500 W I h3p1 d M <br /> TYPE OF WORK (Check): NEW VELL'&7 DEEPEN /-7 RECONDITION /-7 DESTRUCTION 7 <br /> PUMP INSTALLATION /-7 PUMP REPAIR /-7 Pump REPLACE ENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES '_ 'PIT PRIVY : <br /> SEWAdE DISPOSAL FIELD S !2?-` -CESST'OOL;/SEEPAGE PIT OTS <br /> PROP&TY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL � <br /> INTENDED USE ' TYPE OF WELL-. CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Took. Dia. of Well Excavation � 11 <br /> Domestic/private Drilled Dia. of Well. Casing _ _� 6-518" <br /> Domestic/public Driven Gauge'of Casing" <br /> Irrigation Gravel Pack . Depth of Granit tea St�Y <br /> Cathodic Protection .,X Rotary Type of Grout --awimit§ : <br /> Dispersal Other Other Information's L ower <br /> Geophysical Surface Seal Installed B <br /> UMP INSTALLATION Contractor 914 &141Kh11 <br /> Type of Pump . f ' H'P• —: _ <br /> t <br /> PUMP REPLACEMENT: ,�/ State Work Done <br /> a <br /> PUMP .REPAIR: jEV State 'Work Done � <br /> DEQ TION OF WELL: Wall Diameter J ; Approy4mate Depth <br /> G✓����l�r'� Desc be tenial ocedure <br /> I hereby agree to c ly with $11 L ws e isms o the an o u�`in Local. Health District <br /> and the State of California pertaining to or regulating well'construction. Within PIFTEEN DAYS`' <br /> after completion of my work on anew well, i will furnish the San Joaquin Local. Health District f <br /> WELL DRILLERS REPORT of thi well and notify them before butting the-well in use. The above <br /> information is true to th+jbest of. my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL I'NSP'ECTION, <br /> SIGNED INC BY TITLE �" S�.C. <br /> • y <br /> PLAiv ON E SI7 E ..~- <br /> AAR DEPARTMENT USE ONLY .� <br /> PHASE I <br /> %ICATION ACCEPTED BY DATE <br /> a_ -ITI.ONAL COMtiMS: <br /> t � PHAS I INSPECTION PHASE F INSPECT IO <br /> INSPECTION BY DATE -140-7 INSPECTIOP3 BY DATE <br /> --44V76 <br /> E 'H 1426 Rev. 1-74 , <br />