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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued.. 24 <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. 186 and the Rules and Regulations of the San Joaquin Local. Health District.' <br /> hl <br /> JOB ADDRESS/LOCATION Chrisman & Durham Ferry Roads, Tracy, CA CENSUS TRACT <br /> Owner's Name Jos. C. Brichetto Phone 463-0825 (249) <br /> Address 989 Oxford Way, City Stockton <br /> Contractor's Name Western Well Drilling Co., Ltd. Sari Jose License # 25182 Phone 295-4332 <br /> TYPE OF .WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION /_7 -DESTRUCTION /_7. . <br /> PUMP INSTALLATION PUMP REPAIR /X/ PUMP REPLACEMENT <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <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 T- Depth of-Grout Seal <br /> Other Rotary Type of Grout <br /> N Other Other Information <br /> PUMP INSTALLATION: contractor <br /> Type of Pump H.P. <br /> IM <br /> PUMP REPLACEMENT: /IM/ State Work Done <br /> IM <br /> PUMP REPAIR: / / State Work Done _ Tubeline Repair <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth,,. <br /> Describe Material and Procedure <br /> I hereby agree to complylwith 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 t to the best of my knowledge and belief. <br /> SIGNED TITLE President T <br /> `` IM (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I N r' /f f <br /> APPLICATION ACCEPTED BY DATE C <br /> ADDITIONAL COMMENTS: M. <br /> PHASE II GROUT INSPECTION PHAs& HiTywn INSPECTION <br /> INSPECTION BY 1 DATE _ INSPECTION BY / DATE <br /> ,I -_ <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />