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SAN JOAQUIN LOCAL-HEALTH DISTRICT <br /> FW'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;S J,2_74) <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a pel*mit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquini <br /> County Ordinance No. 18622 and the Rules and Re ulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ( CENSUS TRACT <br /> Owner's Name Phone d <br /> c,.9.., <br /> Address City /�® "'�°a,.,,.__ <br /> Contractor's Name IMMTXGS BROS. DRILLING CO.I INC. License # 290833 Phone 522--1031 <br /> 0 W RUMBLE RD. MODESfiO CAL. 95350 <br /> TYPE OF WORK (Check): NEW WELL '/ DEEPEN/7 RECONDITION /7 DESTRUCTION rf <br /> PUMP INSTALLATION / J PUMP REPAIR 17 PUMP REPLACEMENT /7 <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 2 <br /> 1/Domestic/private l--Drilled Dia. of Well Casing 4 <br /> Domestic/public Driven Gauge of Casing �/ ` <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection j,=_Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: .� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: J / State Work Done <br /> PUMP :REPAIR: 17 State Work Done <br /> ESjRUCTION 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 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 GROUT.44G AND A FINAL INSPECTION. <br /> SIGNED a,. TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> 4P} HASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BYNka\LA DATE q-d�S =IS <br /> ADDITIONAL COMMENTS: <br /> P I GROUT INSPECTION P S I FINALINSPECTION <br /> NSPECTION BY DATE -'?S INSPECTION BY DATE Tr"—.%S'7 S <br /> E H 1426 Rev. 1-74 1-74 2M <br />