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SAN ',OAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E.. Hazelton Ave. , Stockton, Calif. � a <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR.WELL CONSTRUCTION OR PUMP PERMIT Permit No:­-7?_=?9W_+RI <br /> �i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED , Date Issued ! -21..70,` <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 with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION 1st House on North .side West of North RiporCENSUS TRACT ' S�S�• <br /> on -ullnt.on South <br /> Owner's Name MARY BORGES' Phone ' 599-3577- <br /> Address <br /> 99-3577- <br /> Address 4 B,_, CLINTON SOUTH RIPON CALIF. City <br /> Contractor's Name Hennlri s Bros. Dri 11 ng ;Cad ---In License #116322 phone 522-!,5643 4 <br /> r t , 7 <br /> V <br /> TYP OF S�TpRK (Ch k) DEEPENS/ -RECONDITION/_7 -..DESTRUCTION�-J f <br /> PUMP INSTALLATION_-/ -/_ /: PUMP-REPAIR / PUMP REPLACEMENT 1-7 <br /> Other <br /> DISTANCE TO NEARE T: SEPTIC TANK 0 _SEWER LINES vo PIT PRIVY ` I <br /> ;SEWAGE DISP SAI: FIELD /Ga` —CESSPOOL/-SEEPAGE PIT '•, . OTHER € <br /> i <br /> INTENDED USE r TYPE OF WELL SPECIFICATIONS <br /> Industrial ,` Cabld'Tool Dia. of Well Excavation 101, _ <br /> x Domestic/private Drilled, j.4 Dia;c;of Well Casings 6�1:'f - <br /> Domestic/public Driven Gauge of Casing , <br /> Irrigation ' Gravel Pack "'-`Depth of Grout Seal' 50 <br /> Other t Rotary--_ T-ype�of .Grout ' Bpntonita <br /> Other �-- <br /> Other Information ' <br /> PUMP' INSTALLATION: Contractor <br /> I Type of Pump H.P. . <br /> f Y <br /> PUMP REPLACEMENT: /' / State Work-Done' <br /> t N0 Si-A AfO Ci;4-017.. <br /> PUMP REPAIR: i /.. / State Work Done • - 7Z - SEAL- 0g�( 4A ,_C <br />' <br /> -P 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 we11;'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 istrue to the best of my knowledge and belief. _ <br /> SIGNED ✓' , # _ TITLE Y.7a mss•A, <br /> I + / (DRAW PLOT PLAN ON REVERSE SIDE ' <br /> FOR DEF T NT USE ONLY <br /> PHASE I - Y �` . t - � <br /> APPLICATION ACCEP" M DATE__ <br /> ADDITIONAL COMMENTS:� . <br /> PHAS II GROUT INSPECT 0 ;'•. PHASE I NAL INSPECTION <br /> E. INSPECTION BY DATE ' - -__INSPECTION BY K LA DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 1W <br /> E H 3.426 �. 4/72 1M . <br /> - <br />