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AP <br /> } SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E, <br /> FODFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466r-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -LT <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE, ISSUED Date Issued -2 7 <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 3200 East Bight Mile Road, <br /> CENSUS TRACT <br /> Owner's Name Tri/Valle Groaners - Plant #4 <br /> �' . Phone 9311531 <br /> Address. - Same as. above _ -M City Stockton <br /> Contractor's .Name Tri/Valley Growers License # Phone 981-1531 <br /> TYPE-OF-WORK-(Check):� NEW WELL /7- -DEEPEN /_7 RECONDITIONESTRU ' - <br /> /—P <br /> -T CTTON <br /> y PUMP INSTALLATION REPAIR /7 PUMP REPLACE <br /> Other /_7 <br /> — <br /> f 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 /> PECIFICATIONS - 4 <br /> Industrial Cable Tool Dia. of Well Excavation 161-' <br /> Domestic/private Drilled Dia, of Well Casing 14+ <br /> Domestic/public Driven Gauge^ of Casing <br /> 1-141 <br /> Irrigation x Gravel Pack' Depth of Grout Seal 220' `9 <br /> Cathodic Protection Rotary Type-of Grout <br /> ravel <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor p <br /> FTypeof Pump -- H.P. <br /> PUMP REPLACEMENT: ! / / State Work Done <br /> PUMP 'REPAIR: /7 , State Work Done _ f <br /> ES,TRUCTION OF WELL: Weli'Diameter 14" _ Approximate'Depth 256' <br /> Describe Material and ProcedureEscavate 3 ' below 'p-round surface; fill with <br /> crushed gravel or sand ' with concrete_ _ <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 theta 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 TO GRPUTING ANDA TNAL INSPECTION. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSL=SIDE <br /> -- -- FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY A9/7 Y�- <br /> - DATE <br /> iii ADDITIONAL COMMENTS: <br /> PHAS II U INSPECTIO P -IIIWINAL INSPECT 0 <br /> INSPECTION BY DATE INSPECTION DATE <br /> E R 1426 Rev. 1-74 1-74 2M <br />