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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> rOF. 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 THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 12 -1173 <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.Jbaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION S.W. CORNER OF WEST RIPON & U TIN , CENSUS TRACT <br /> Owner's Name JERRY FISIER " <br /> Phone _ 982-1510 <br /> Address _ 17747 E. HWY 120 City ' RIPON � <br /> Contractor's-Name--h7EN1NING84 EROS.- DRILLI-ILIOLCj0' iI +I-C=j,•-- Lisense_#z:_- 62-2.Phone,..,5.22-56}+� <br /> 2 OO W. RUMBLERD. MODE TO <br /> TYPE'OF WORK (Check): NEW WELL/'/ DEEPEN -/—/ RECONDITION/_7 DESTRUCTION /_7 <br /> PUMP `INSTALI:ATION J J POMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other: / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER FINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial ! Cable Tool Dia. of Well Excavation 1 ()tl <br /> X Domestic/private Drilled Dia. of Well Casing 6,1y-tl <br /> Domestic/public t Driven Gauge o£ Casing 12 GA [ <br /> Irrigation - * Gravel Pack ' Depth of Grout Seal 50t <br /> OtherRotaryType of Grout BENTONITE i <br /> E Other Other Information SLAB– BY O,'TER <br /> • tt <br /> PU?-II' INSTALLATION Contractor I <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP 'ZEPAIR: <br /> State Work Done <br /> ,DFgTRUCTION 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 Health District <br /> and the State of'Califorai_a 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 al <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the be tfof my knowledge and belief. { <br /> SIGNED i <br /> _ TITLE <br /> ( RAW LOT 'PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED .BY 17 TE <br /> ADDITIONAL COUNTS: <br /> PHA E II GROUT INSPECTION P II INSPE!r4 <br /> INSPECTION BY DATE <br /> INSPECT I N BY TE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E <br /> H- 1426 <br />