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' SJAW TOAQUIN LOCAL HEALTH DISTRICT vO� <br /> FOE OFFICE USE: 1601 Hazelton Ave. , Stockton, Cal <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 - 8 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7>31-7 9 <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 ihe-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 /> JOB ADDRESS/LOCATION Stoneridge CENSUS TRACT <br /> Owner's Name Don Cose Phone 836-0422 -�- <br /> Address P. O. Box 326 City Tracy 4 <br /> Contractor's Name HPnn� inya,_Brot-herc License #r57 Phone 545-1185 <br /> 90813 <br /> TYPE OF WORK (Check): NEW WELL k T DEEPEN '/-T RECONDITION DESTRUCTION /-T \ <br /> PUMP INSTALLATION. / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other /-T <br /> DISTANCE TO NEAREST: SEPTIC T SEWER S PIT PRIVY <br /> SEWAGF� DIS FIELD O(� ESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE '• TYPE OF WELL CONSTRUCTION SPECIFICATIONS \. <br /> Industrial_ J 7Cable Tool Dia: ,of .Well Excavation 11 it or 1,7 <br /> Domestic/private x Drilled, Dia. of Well Casing 6" <br /> Domestic/public Driven Gauge. of Casing vxzc IAn r <br /> Irrigation — Gravel Pack Depth of Grout Seal Sn ' -- <br /> Cathodic Protection Rotary Type of Grout Cnncrete <br /> Disposal Other' Other Information <br /> Geophysical Surface Seal Installed By: Fritas <br /> PUMP INSTALLATION; Contractor Fritas Electric <br /> Type of Pump, Jet Pump 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 Health District <br /> and the State of California pertaining to or regulating well'-construction. Within FIMIN DAIS <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 12 GROUTING.-.AND A FINAL INSPECTION. <br /> t ' , JSIGNED a <br /> V t J- Ar ;!(DRAW P W PLAN AN REVERSE SID <br /> FOR DEPARTMENT <br /> PHASE I <br /> APPLICATION ACCEPTED. BY d DATE <br /> ADDITIONAL COMMENTS: ' <br /> PHASE II GROUT INS CTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> r. f Gym Sr, fin• . ?7`---1�-t ' <br /> E H 1426 Rev. 1-74 .,, ' <br /> 3/76 2M <br />