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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EOF..OIFTCE LiSL: 1601 E. Hazelton Ave. , Stockton, Cali€. <br /> k. Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL- CONSTRUCTION OR PUMP PERMIT Permit No.,3�J�W <br /> i THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1.2 -2j�73 <br /> } (Complete In Triplicate) �-T-7-��D- 36 <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 Sati':Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION S.W. CORNER OF WEST RIPON & AU "4$" . CENSUS TRACT <br /> Owner's Name JERRY FISHER <br /> Phone 82-1 .511+ <br /> Address 1774Z E . HWY 120 City ' RIPON <br /> Contraactor's-Name�EENNINGS4.$R-OS.� DR>ILL-T- G, CO.� ;I-NCS== L" 'c�rrse � ;6 2.2-P'hone,,-,5`2 <br /> 2 00 W. RUMBLE RD. MODESTO <br />'r TYPE"OF WORK (Check) : NEW WELL -/V DEEPEN -/_/ RECONDITION '/—/ DESTRUCTION /_7 <br /> PUMP TNSTALtATION / PL'I-IP REPAIR '/—/ PUMP REPLACEMENT /_7 fes' <br /> Other; <br /> `r �•4 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE <br /> TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial' ± Cable Tool Dia. of Well Excavation 1 Ort <br /> X Domestic/private j Drilled Dia. of Well Casing 61rr <br /> Domestic/public r Driven Gauge of Casing 2 G f <br /> Irrigation Y } ►_ _ Gravel Packs Depth o-' Grout Seal Ot <br /> — Other IX YRotary Type of; Grout BENTONITE <br /> 1 Other Other Information SLAB- BY OWNER <br /> t +� <br /> PUMP INSTALLATION:' Contractor I <br /> Type of Pump H.P. 71�S <br /> PUMP REPLACEMENT: / / State Work Bone <br /> PUMP 'ZEPAIR: Fes/ / State Work~Done <br /> ,DFsTRUCTION OF'WELL: Well Diameter <br /> 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 al <br /> WELL DRILLERS REPORT of. the well and notify them before putting the well in use. The above <br /> information is true to the be t- .of my knowledge .and belief. <br /> SIGNED <br /> TITLE <br /> ( RAW LOT PLAN ON REVERSE SIDE , <br /> t <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I r <br /> APPLICATION ACCEPTED -BY TE <br /> ADDITIONAL COM1vMNTS: <br /> PHASE 11 GROUT INSPECTION P II N INSPECT N <br /> INSPECTION BY DATES -,T _- INSPECTT N BY TE <br /> GALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> ,-E H-1426 <br />