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_- � SAN JOAQUIN LOCAL HEALTH DISTRICT + <br /> FOR QFFI�,E• USE: 1601 E. Hazelton Av ..,.Sgockton, Calif. <br /> Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION 0'R PUMP PERMIT Permit No. <br /> �I THIS. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued fig' <br /> n <br /> u (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 Sart Joaquin- <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> I�. JOB ADDRESS/LOCATION <br /> 28700 S. Tracy Rd.- 1/8 Mile South of Linn. CS <br /> c st side <br /> Owner s Name Jim Ledbetter Phone $35—"99 _ r <br /> 28700 .'S.. Tracy Rd. Cit Tracy, Ca. <br /> Address Y . <br /> Contractor's Name Hennings Bros . Drilling Co. ; Inc. License #290813 Phone 54.5-1185 <br /> 3�25 Pelandale Ave. Modesto Ca. 95350 <br /> TYPE"OF W _ _ _- <br /> " ORK` (Check) : NEW WELL DEEPEN <br /> RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT 09 <br /> Other / / V <br /> DISTANCE TO NEAREST: SEPTIC TANKS—SEWER LINES 10 ' t+ PIT PRIVY R <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> PROPERTY LINE OldATE .DOMESTIC WELL 401 PUBLIC DOMESTIC:WEL,L•', <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICA,'Y\L <br /> Industrial. „ Cable Tool Dia. of Well Excavation `: ' , rrl'::. 11:'t A <br /> f Domestic/private'! X Drilled Dia, of Well Casing (3tt < <br /> Domestic/public �i Driven Gauge of Casing <br /> Irrigation X Gravel Pack Depth of Grout Seal 501 Cement <br /> -Cathodic Protection X Rotary Type of Grout Gement Seal <br /> k bisposal ;, Other Other Information Slab by Owner <br /> iGeophysical Surface Seal Installed B , <br /> PUMP INSTALLATION: !Contractor <br /> Jype of Pump H.P. <br /> PUMP REPLACEMENT: `�• ,,+/ / State Work Done <br /> 3- <br /> PUMP .REPAIR: / / ,State Work ,Done. <br /> DESTRUCTION OF WELL: 'r.Well Diameter Approximate Depth _ <br /> II.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,1work on a new well_, I will furnish the San Joaquin Local Health District a <br /> ! WELL DRILLERS REPORTof .the well and notify them before putting the well in use. The above <br /> ai <br /> information is., tr"i' " toj the best' of my knowledge and belief. I L CALL FOR OUT ON <br /> IN EC I <br /> PRIOR TO GROUTING.,ANDA:A FINAL INSPECTION. DELLA MSA B R <br /> SIGNED ,. . , INC. TITL <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> t FOR DEPARTMENT USE ONLY <br /> 4 ' <br /> PHASE I .I <br /> r APPLICATION ACCEPTED BY DATE~Av <br /> ADDITIONAL COMMENTS: 2 i <br /> --� <br /> P II OUT INSPECTION P ._ E III/ IN �DATE�- <br /> b/77 <br /> ON <br /> INSPECTION BY DATE �.� INSPECTION BY ' " ` {/���GF1 <br /> E H 1426 '-Rev. • 1- 74 <br />