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FOOF�'ICE USE: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> H�` 1601 E. Hazelton Ave. ,' Stockton, Calif. <br /> f Telephone: (2D9) 466-6782 <br /> APPLrCATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In Triplicate) Date Issue�(�4Ri 1 <br /> ' Application is hereby made to the San Joaquin Local Health District fora permit <br /> struct <br /> and/or install the work herein described. <br /> County Ordinance No. 1862 axil the Rules andThis RegulaPionsPlicatofnthe is made in compliancetwithn5an Joaquin <br /> San Joaquin Local Health 'District. <br /> JOB ADDRESS/LOCATION 10880 E. Graves Manteca, <br /> Owner's Name Bill Ferriera, CENSUS TRACT <br /> Phone <br /> AddresslD8$D E rave <br /> City <br /> Contractor's Name Ix, Stanislaus-PUMP & Machine Cox <br /> License # Phone <br />� <br /> TYPE OF WORKM1 (Check) ; NEW'.WELL � �� - • - _ - . ^_ <br /> /? DEEPEN _ s <br /> . PUMP INSTALLATION / / RECONDITION /_� DESTRUCTION /? <br /> Other �/ PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Cf <br /> DISTANCE TO NEAREST: SEPTIC 'TANK <br /> Oc. I <br /> SEWAGE DISPDSAL FIELDWER LINES PTT PRIVY. <br /> CESSPOOL/SEEPAGE PIT <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL DTHER <br /> INTENDED USE TYPE OF WELL PUBLIC. DOMESTIC WELL <br /> Industrial _ i Cable Tool CONSTRUCTION SPECIFICATIONS <br /> D <br /> Domestic/private Dia. of Well Excavation <br /> Domestic Drilled Dia. of Well Casing <br /> /public Driven <br /> x Irrigation ! Gravel Pack of <br /> of Casing <br /> Cathodic Protection ; Depth of Grout Seal <br /> Disposal Rotary Type of Grout <br /> Geophysical ?— Other Other Information <br /> �^ Surface Seal Installed By: <br /> PUMP INSTALLATION: <br /> Contractor Stanislaus pwn & Mac in <br /> ry <br /> Type of, Pump Johnston Turbine um <br /> PUMPREPLACEMENT: - , <br /> /�/ State Work Done <br /> PUMP .REPAIR.: / . State Work Done _ <br /> ,. . ._ <br /> DESTRUCTION OF WELL: Well Diameter <br /> DescribeApproximate <br /> Material and Procedure Depth <br /> I hereby agree to comply with all laws and <br /> and the State of Calregulations of the San Joaquin Local Health. District <br /> ifornia 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"Distric <br /> 4ELL DRILLERS REPORT of the well and notify them before <br /> Cnformation is true to the-best of my-knowledge and belief putting the..well in use. The above t a <br />'RIOR TO G UTING AN FI�TAI, INSPECTION. <br /> Y I WILL CALL FOR A GROUT INSPECTION <br />'IGNED This is read for ins�ppectio 3-9_ $ <br /> DRAW Pto"T PLAN ON REVERSE TSID <br />'HA� SE I t FOR DEPARTMENT USE ONLY <br /> PPLICATION ACCEPTED BY <br /> DDITIONAL COMMENTS: A DATE � <br /> PHASE II GROUT INSPECTION <br /> NSPECTION BY DATE PHASE I FIN INSPECTION <br /> INSPECTION B .DATE A <br /> E H 1426 Rev. 1-74 PLCN P � <br /> 3/76 ?urA <br />