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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFi;OFFICE USE: 1601 E. Hazelton eve. , Stockton, Calif. <br /> Telephone: (209) 466-678 . <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE 'ISSUED Date Issued ro-.37s <br /> (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 and Regulations of the San Joaquin Local Health District'. <br /> IL45i Z c_tia � r�3- �o-off <br /> JOB ADDRESS/LOCATION FRENCH CAMP RD.- 1/8MI E. OF JACKTONE RD... f CENSUS TRACT <br /> NORTH SIDE <br /> Owner's Name PhoneV\ <br /> Address 20828 JACKTONE RD„ � � City . RTvnN <br /> Contractor's Name ennin Bro Drilling n C e License # 29081 �Phone <br /> 2 00 W. Rumble Rd Modesto <br /> TYPE OF WORK (Check) : NEW WELL/g7 DEEPEN '/r7 RECONDITION /-7 DESTRUCTION _ <br /> PUMP INSTALLATION f-1 PUMP REPAIR -/-7-pump REPLACEMENT /7 Z- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD _ CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE --PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 24" <br /> Domestic/private Drilled Dia. of Well Casing 6" <br /> Domestic/public Driven Gauge of Casing -1/16t[ <br /> -- Irrigation Gravel Pack Depth of Grout Seal none <br /> Cathodic Protection Rotary Type of Grout none <br /> Disposal Other Other Information � lab by owner <br /> Geophysical \ Surface Seal Installed BY: 'Emi$Ix - <br /> PUMP INSTALLATION: Contractor \ <br /> Type of Pump H.P. Z <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP ,REPAIR: /-7 State Work Done <br /> ARES-TRUCTI_ON._OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> cam- ZZ, . - <br /> I hereby agree to comply with all laws and regulations of th an Joaquin Local Health District <br />. and the State of California 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 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,best of my..knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> .PRIOR TO MUTAND FINAL INSPECTION-.) <br /> SIGNED TITLE <br /> W PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I _ <br /> APPLICATION ACCEPTED BY oZ DATE , ..Z <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III INAL INSPECTYION <br /> INSPECTION BY DATE INSPECTION BY G /. - -DATE <br /> E H 1426 Rev. 1-74 ;:.: - -- — --4175-----2M - <br />