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SAN JOAQUIN LOCAL HEALTH DISTRICT _ <br /> FOE"OFFICE USE: , 1601_ E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 71 - � cp' `' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7-3/- <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 Joag4in,Local Health District. <br /> JOB ADDRESS/LOCATION Stoneridge Z z 3 P CENSUS TRACT ; <br /> Owner's Name Dan COse Phone 36-042 <br /> Address . P. 0. Box 326 city TracyC <br /> Contractor's #rr Phone 545-1185 <br /> s Name -Henning Brothp-i:a <br /> ~ <br /> TYPE OF WORK (Check): NEW WELL DEEPEN/ / RECONDITION I I DESTRUCTION %j <br /> _ TION r PUMP REPAIR / / PUMP REPLACEMENT /� } <br /> . PUMP INSTALLATION / / f <br /> Other / / 1�5 <br /> DISTANCE TO NEAREST: SEPTIC TAN SEWER S PIT PRIVY <br /> SEWAGE DIS FIELD p�:4- ESSPOOL/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 111, -Qr ]L211 <br /> X Domestic/private x Drilled Dia. of Well Casing 611 <br /> Domestic/public Driven Gauge of Casing <br />} Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic- Protection Rotary Type of Grout _ ConCretP _ <br /> Disposal Other Other Information - <br /> Geophysical. Surface Seal Installed B ritas <br /> PUMP INSTALLATION; Contractor Fritas Electric <br /> Type of Pump Jet Pum H.P. 1 <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP .REPAIR: / :/ State Work Done <br /> DESTRUCTION 'OF. WELL: Well Diameter . Approximate Depth " <br /> Describe Material and Procedure -, <br /> I hereby agree to comply with all laws and, regulations'of the San `Joaquin Local Heal h District' <br /> and the State sof' Calif ornia, pertaining to or regulating well'constructian. Within FIFTtIN DATYS <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 puttingpthe..well in use. The above <br /> information is true to. the-beat of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTIQN.- <br /> PRIOR jq G TIATG D A FINAL INSPECTION. <br /> SIGNED L0 NNAA -�. TITLE �J <br /> h <br /> D W.. PLAN 'ON' R$E SI UU <br /> f 1' <br /> FOR DEPARTMENT <br /> PHASE I <br /> APPLICATION ACCEPTED.BY C7 >�-P�G DATE <br /> ADDITIONAL COMMMTS: <br /> PHASE If GROUT 1145 CTION PHASE III FINAL INSPECTI N` <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> V76 . <br /> ���_ <br /> "E H 1426 Bev.}'1-74 - �.. � - <br />