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f SAN JOAQUIN LOCAL HEALTH DISTRICT z <br /> •tea- <br /> t FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 4 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.? <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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. 1862 and the Rules and Regulations of the San Joaquin Local Health District;. <br /> JOB ADDRESS/LOCATION StoneridcTe3�6� U _ _ CENSUS TRACT f <br /> Owner's Name Don Cose Phone _ <br /> Address P- 0.O. Box 326 City _ Tracy <br /> F <br /> 'Contractor's Name Henning-Brothers License # �W Phone 545_1185 ` <br /> TYPE OF WORK (Check) : NEW WELL ',k DEEPEN -7 RECONDITION / DESTRUCTION /_7 <br /> PUMP INSTALLATION -/ / PUMP REPAIR -/ / PUMP REPLACEMENT /? D <br /> Other 1_7 _ <br /> DISTANCE TO NEAREST: SEPTIC TAN VS EWE ES PIT PRIVY a` <br /> SEWAGE DISPO FIEL 4- CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -""T <br /> A MESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well. Excavation 11.°-12" <br /> r x Domestic/private x Drilled Dia, of Well Casing 1G!l <br /> - .-Domestic/public Driven Gauge of Casing e ' PVC 1.60 - <br /> Irrigation Gravel Pack Depth of Grout Seal 50' <br /> Cathodic Protection Rotary Type of Grout Concrete • <br /> Disposal Other °. Other Information ; <br /> ,Geophysical f"' Surface Seal Installed BY: Fritas <br /> PUMP INSTALLATION: Contractor _ F'ri+-as . F-Iggt-r;r_ <br /> Type of Pump ,Tet j2 mp H.P. "1 <br /> PUMP REPLACEMENT: / / State Work Done y _- <br /> PUMP-„:REPAIR:-- ,./ / F - <br /> State Work-Done---- A <br /> DESTRUCTION '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 wry ' <br /> and the State. of California pertaining to or regulating well'constyruction. Within FIFTEEN DAIS, <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 IdSPE'CTIO�T <br /> PRIOR TPMUTING AND A FINAL INSPECTION. : <br /> SIGNED C o TITL <br /> V �'' D W PW`PLAN ON RSE SIDE <br /> FOR DEPARTMENT USE 0 ` <br /> PHASE I Jf/ }}---- <br /> APPLICATION ACCEPTED BY / ree DATE <br /> ADDITIONAL COMMENTS: 'I <br /> PHASE I GROAT INSPECTION DATE <br /> III FINAL INSPECTION <br /> INSPECTION BY ►- DATE -7 INSPECTION BY DACE <br /> ' E76 2E4 <br /> �, E H 1426 Rev. 1-74 �” <br />