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All <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0K;OFFICE USE: '1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ] � <br /> i 1 <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued <br /> I . -(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 Joaqut <br /> County Ordinance No. `1862 and the Rules and Regulat ns of the San -Joaquin .Local Health District. <br /> 2739 South Ufa cArthur 3A �'�ile northh ff Rd. Tracy <br /> JOB ADDRESS/LOCATION 'CE�SU �T <br /> i <br /> Owner's Name ' Paul Rinauro Phone 835-6536 <br /> r, ,Address 27398 So: Mac Arthur City Tracy, Cal. <br /> Contractor's Name} H$nnings Bros . Drilli_hg Co. Inc'.*' ' License' # . 290813 Phone 522-1031 <br /> 2560-West Rumble TO. MoUesto, al: 95350 <br /> TYPE OF WORK (Check): NEW WELL­)X-T-ZDEEPEN '/7 RECONDITION %7 DESTRUCTION 1-7 <br /> .� <br /> PUMP INSTALLATION`/-7 PUMP REPAIR / / PUMP REPLACEMENT f_7 G <br /> Other <br /> DISTANCE TO-"'NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> ' SEWAGE DISPOSAL FIELD F CESSPOOL/SEEPAGE PIT OTHER <br /> ILIJ PROPERTY LINE - PRIVATE�DOMESTIC WELL PUBLIC DOMESTIC WELL v <br /> INTENDED'USE ;TYPE OF WELL CONSTRUCTION. SPECIFICATIONS <br /> r Industrial.- Cable--Tool- Dia. of Well Excavation. 11 <br /> Domestic/private Drilled Dia.,_of Well Casing - <br /> Domestic/public Driven Gauge"Nof, Casing 12 Ga <br /> Irrigation Gravel :Pck De th of'`:Grout Seal. <br /> � �, °,�, p . <br /> Cathodic PTOtect_ion _g_ Rotary Type of Grout entonti e <br /> Disposal Other Other; Information a y owner <br /> Geophysical - Surface Seal Inst_al_led By: _ <br /> PUMP INSTALLATION: <br /> Contractor, _ <br /> ' <br /> Type of Pump - - H.P. <br /> R <br /> k PUMP REPLACEMENT: / / ' State Work Done <br /> A. <br /> PUMP-REPAIR.: - <br /> DE&TRUCT.ION OF WELL: Well Diameter i Approximate Depth�..�. <br /> T Describe`Maierial and Procedure E <br /> I hereby agree to comply with all laws and regulations of the San 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 -anew well, I will furnish the San Joaquin Lacol Health District a <br /> WELL DRILLERS REPORT of :the well- -,arid notify them before putting.the..well. in use.... The 7aboye <br /> information is true to the-best-of- my-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED &, /fir ;s `` TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> ?t FOR P T USE ONLY <br /> PHASE <br /> APPLICATION ACCEPTED :- - DATE <br /> "� �}' '; 5 �^ <br /> � - r _ �''^- �`� -- - <br /> ADDITIO9)1I. COMMENTS: -Y w <br /> KEWI ROUT3INSPECT. N P I INAL INSPB N <br /> INSPECTION BY DATE -' INSPECTION BY DATE <br /> E H 1426 'R,-u. 1-74 h/75 - 2M <br />