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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: ' 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone, (209)' 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is 4ereby made' to �the San Joaquin Local Healthistmade inra permit compliancetwithnSanuJoa4ein ; <br /> and/ox install the work herein described. This application <br /> County Ordinance No.,,1862�andthe Rules and Regulations of the San Joaquin Local Health <br /> District-0 S7-zoo - 2--& - . . <br /> JOBAD�DRESS/LOCATION H 88 a rox. 400' North of Kettleman CENSUS TRACT f <br /> Ln. , on West side �f road (Proposed Fruit Stand) <br /> Phone <br /> Owner's Name LEONARD GINOCHIO <br /> City Antioch <br /> Address 3724 Heritage <br /> .License �i 309031 Phone:727--5548 <br /> i Contractor's Name Goehrin Pum & IrrigationInc. .. <br /> I TYPE OF WORK .(Check) -:, -NEW,WELL /=/ 'DEEPEN"� `RECONDITION EREPLACEMEN /� <br /> PUMP INSTALLATION / / PUMP REPAIR / ' /`, ,.,PUMP <br /> Other)&/Alteration & change of dischar e on turbine um <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ PIT PRIVY <br /> OTHER <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT.' _ <br /> ` PROPERTY LINE » PRIVATE DOMESTIC WELL ='`PUREIC DOMESTIC WELL <br /> i INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well'Excavation <br /> Indu <br /> ( Induprivate Drilled Dia. of We`ll Casing <br /> Domestic/private . <br /> 6 Driven Gauge._ of Casing <br /> Domestic/public <br /> Irrigation Gravel Pack DeptY►�,of Grout Seal ` <br /> Type of Grout <br /> ( Cathodic Protection Rotary Other Information <br /> I . Disposal Other <br /> Geophysical + Surface 5ea1 Installed B <br /> PUMP INSTALLATION: Contractor .` H.P. <br /> Type of Pump _ <br /> ` State Work Done ' <br /> k PUMP REPLACEMENT: �/ _ - <br /> t <br /> ' State Work.Done,,_.,Chan_:Chan ed manner ,of dischar e from um <br /> PUMP .REPAIR: I _ <br /> -t:le-standpipe==see reverse <br /> - --.Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter`% . <br /> Describe Mate," aD.atid Proced he <br /> 41 hereby agree to comply with all laws and xeregulatinglowell�'co struction.San Joaquin LoWithinaEIFTEENtAAYS <br /> land the State of California pertaining to. or <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS RT"of�tY►e well anabove <br /> d noifyhem before. efI WILT.-CALL FOR AeGItOUTe7NSFECTION. <br /> t informatio ue _to._therbest�of:�my knowledge_nanl�.bel <br /> PRIOR TO R G D A FINAL INSPECTION. TITLE <br /> SIGNED & <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPART NT USE ONLY <br /> tPHASE I DATE <br /> APPLICATION .ACCEPTED BY <br /> ADDITIONAL COMMENTS: PHASE II /FINAL INS ECTION <br /> PHASE II OUT INSPECTION INSPECTION BY DATE <br /> INSPECTION BY DATE / f <br />