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SAN JOAQUIN Al - HEALTH.DISTRICT <br /> N?0VO CE IISE 1601 E. Hazelton Ave., ;Stockton, calif. <br /> Telephone: J209) 466--6781 I <br /> APPLICATION.FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -.s3�� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application Is liereby'made `to the San Joaquin Local Health District for a permit to copstruct <br /> and/or install the work herein described. This application is" made in compliance with San Joaquin <br /> CountY,'Ordinance No. 1.862 and the Rules and Regulations of the San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION <br /> ' 42 CENSUS TRACT <br /> Owner's Name FRANKLIN -COLEi <br /> Phone 8 ..p W $ <br /> Address 28265 CHRISMAN RD`. <br /> City , TRACY <br /> Contractor's Name HENNINGE_ABR S.. DRILLING C_Q�0T-NC, License # Phone <br /> V <br /> TYPE OF iiORF.�(Checic)-:;�-NEW�WELL.- ,..DFMENo, RECONDITIQN-/�DESTRUCTION - ` <br /> PUI P INSTALLATION %/ PUMP REPAIR %/ PUMP REPLACMfla T �f <br /> Other _._ <br /> DIST/�CB TO NEAREST'' SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD <br /> CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTEMED USE TYPE OF WELL CONSTRUCTION SPECIFIICTS <br /> Industrial Cable Tool Dia. of. Well Excavation 111: Cl� <br /> _ Domestic/private Drilled Dia. of Well Casing 6:1 <br /> Domestic/public Driven Gauge of Casings <br /> I60 WA TL <br /> rrigation �- Gravel Pack Depth of Grout Seal- t <br /> Cathodic Protection Rotary Type of Grout BENTONTTE <br /> Disposal Other Other Information' SLAB-BX <br /> GeophysicalSurface Seal Installed $ QWER . <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P, <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP -'REPAIR: / / State Work Done <br /> DESTRUCTION 1 OF WELL;e We11 Diameter <br /> Approximate Depth " <br /> Describe Material and Procedure <br /> I hereby agree to comply with an laws and regulations of the San Joaquin Local Health iatrict <br /> and the State of California pertaining to or regulating well"construction. Within FIFTEEN DAYS i <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 in.use.. The above <br /> information is true to thebest of- my.knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO NG ANDA F AL INSPECTION. <br /> SIGN TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �.. <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA S II INSPECTION <br /> INSPECTION BY , ; DATE ✓ INSPECTION BY ATE <br /> r- <br /> E H�,1426 . Rev. 1-74 - * 1/77: - , 2M <br />