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^* Y SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO&,.OFFICE USE. 1601 E. Hazelton Ave. , Stockton, Calif. �} <br /> Telephone; (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. lv,. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 /> JOB ADDRESS/LOCATION I-5 and Durham ferry Road �31Q�lc�,�}ui� ►7„ CENSUS TRACT <br /> Owner's Name Thomsen Farms, Inc. Phone <br /> Address 2365 W. D rham Ferry Road City ' Tracy <br /> Contractor's Name Western Well Drilling Co., Ltd.. Licena 25182'Phone 295-4332 <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN '/-7 RECONDITION /-7 DESTRUCTION /-J <br /> PUMP INSTALLATION /W PUMP REPAIR /-7 PUMP REPLACEMENT 17 <br /> Other /-7 ""- <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 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface, Seal Installed By:..._.. <br /> PUMP INSTALLATION., Contractor <br /> Type of Pump vertical H.P. ..1,� <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR_: /7 State Work Done <br /> ,?ES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> p <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 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 y knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR T GROU D A FINAL INSP ION. <br /> SIGNED TITLE President 6/9/77 <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �- <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III RI AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE <br /> E H 1426 Rev. 1-74 1-74 2M <br />