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Page 20 of 51 <br /> -' - u SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> POb 0 yCE use: 1601 E. Raselcon Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7_3?/ <br /> THIS PERMIT KXPIRPS 1YEAR FRom DATE ISSUED Date 124=d <br /> (complete implicate) <br /> Application is hereby made to the San Joaquin local Health District for a permit to construct <br /> and/or install cho work herein described. This application is made in compliance with Sao Joaquin <br /> -County Ordinance Nn. 1862 and the Rules add Regulations Of the San Joaquin Local Realth District. <br /> : <br /> roe ADDRESS/LOCATION _ 23198 SOu_ th Frederick Avenue census TRACT <br /> Ovaes'a Name Tom 3msliel P Phode 599+A603 <br /> iddreas 23198 S. Frederick Ave. City Ripon <br /> contractor's Blame �e nines Bros..Dri111n CO. fine._ jAce S�11 's2 Phone $225643 <br /> Zj V nuutuA. Act. I. ' - <br /> YPE OF WORK (Check): NEW WELL /)XF DEEPEN /7 RECOND1T10N /7 DESTRUCTION L-7 <br /> PUMP INSTALLATION 1-7 PUMP REPAIR L7 PUMP REPLAmmLKT /7 <br /> Other /� <br /> Irl <br /> ISTAaSCB TO NEAREST: SEPTIC TANK SEWER LINES FIT PRIVY <br /> SEWAGE OISPOSAG FIELD CESSYOOL/SEEPAGE PIT_ OTHER <br /> INTFWJ)ED Usk TYPE-OF WELL CONSTRUCTION SPECIFICATIONS ' <br /> Industrial Cable 'Tool Dia, of Well Excavation gnu �. <br /> Domestic/publico , Drilled Diu. of Nell Casing _®12u <br /> Domestic/public Driven Gauge of Casing 12- 1/76-1 <br /> X Irrigation x Gravel Pack Depth of Grout Seal <br /> Other _� Rotary Type of Grout <br /> Other Other Infornntion 0.- <br /> - 1 �p <br /> MW VISTALLATION: Contractor C- Til <br /> Type of <br /> .HP REPLACEMENT: Store Work Done i <br /> tare Work Do <br /> PUPR REPAIR: � f� stare Work Dodo ' <br /> -'STRUCTIION OF WELL: Well Munster Approximaeo Depth <br /> Describe Nnterial and Procedure _ <br /> I hereby agree to comply with ail lnws and regulatlans of the San Joaquin Laval Health Diaerict <br /> 211d the Stmt of CalifOrdla portoining to or regulating well construction. Within FIFTEEN DAYS J <br /> ret completion of my work on a new well, 1 -111 furnish the San Joaquin Local Health District a <br /> LL DRILLERS REPORT of the well and notify them before Putting the wall In use. The above <br /> .«formation is true to the beet of my knowAedge and belief. <br /> 1 � � <br /> LICHER _ TITLE <br /> (DARN P • LAN ON REVERSE SID0 <br /> 'MSE I <br /> FO DEPMM—=T USE ONLY - - <br /> —� - / l <br /> WFLIC <br /> ATION ACCEPTED 3Y "J2 ii ! _ ATE <br /> -"ITI <br /> '�DITIONAL CO <br /> PRASZ <br /> PRASE II CROUT INSPECTIONE F INSPECTION <br /> l <br /> SPECTLON BY DATE INSPECL__ pATg VX <br /> CALL 1OR A GROUT INSPECTION PRIOR TD GROUTING AND FINAL INSPECTION.' 111 <br /> - E N 1426 7/72 IM <br /> )/2011 <br />