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SAN JOAQUIN LOCAL HEALTH DISTRICT Ad 3 y <br /> FOfi OFFICE USE: 1601 Hazelton Ave. , Stockton, Cal <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.? 9-Q7,S <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ^7-31- <br /> (Complete <br /> 7-3/_(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 w�and ppRegulpations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Stoner id4'e"' L �cJ:,,.., U 0A1-,,X CENSUS TRACT <br /> Owner's Name Don Cose Phone A16-0422 <br /> Address P. O. $ox 326 City Tract/ <br /> Contractor's Name Henning Brothers License # d57 Phone '545-1185 <br /> 7gnR1 1 i <br /> TYPE OF WORK (Check): NEW WELL Ac DEEPEN 'j`7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / . PUMP REPAIR / /PUMP REPLACEMENT FT O <br /> Other /'7 <br /> DISTANCE TO NEAREST: SEPTIC TANYJ, 1qtj;/SPIT PRIVY <br /> SEWAGE DISPO FIEL yy�ROD iCESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY,LINE - PRIVA�TE�OM STIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial - Cable Tool` Dia, of Well Excavation jilt-1211 <br /> x Domestic/private x Drilled Dia. of-Well Casing 6" <br /> Domestic/public Driven j Gauge of Casing _ PVC 160 <br /> Irrigation Gravel Pack Depth of Grout Seal 50' <br /> Cathodic Protection Rotary Type of Grout Con"ra+a <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: Fritas <br /> i. <br /> PUMP INSTALLATION: Contractor _Pritas '.Rlectri <br /> Type of Pump .Ta+ Puma f H.P. 1 <br /> N. <br /> PUMP REPLACEMENT: . %/ State Work Done- <br /> PUMP .REPAIR: /7 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and procedure -c <br /> I hereby agree to comply with ail laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or •regulating well'construction. Within FIYTEEM DAYS <br /> after completion of my work on a new welly 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 beat of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR OUTING AND A FINAL INSPECTION. • ` <br /> SIGNED `,j n i ' TITLN 1.�• <br /> L t..Gi ' N ON REVERSE SIDE <br /> W-P PLA <br /> FOR DEPARTMENT USE 0 <br /> PHASE I / 7- 3 <br /> APPLICATION ACCEPTED BY / eG DATE <br /> ADDITIONAL COMMENTS: ' <br /> PHASE XI GROUT INSPECTION PHASE III FINAL INSPECTION , <br /> INSPECTIONBY Cr- DATE F,• '9 -7-1 INSPECTION BY DATE <br /> 3/76 2H <br /> E H 1426 Rev. 1-74 .. _ <br />