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A ' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FY <br /> OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 89t <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No• �G� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �6, <br /> (Complete In' Txiplicate) <br /> Application is hereby made tolthe 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 Mi. South Fairchild Road & 3/4 Mi. West Jack TonTENSUS TRACT <br /> Owner's Name Ed Podesta, Phone <br /> 12250 E. Fairchild Road, Stockton, Cal-if. 95205 City <br /> Address , <br /> Contractor's Name Purviance DriTlers,Box 64 .indeCal.if. License # ?4.0-'107 Phone ' 931-44 93'1-4 <br /> ,In, 68 E <br /> 95236 <br /> _ <br /> TYPE F WORK (Check) : NEW WELL J DEEPEN / / RECONDITION /X7 DESTRUCTION /_7 <br /> PUMP INSTALLATION J / ' PUMP REPAIR- / / PUMP REPLACEMENT <br /> Other 1_7 <br /> DISTANCE TO NEAREST: SEPTICkTANK 1. 5of __--SEWER•LINES- ..PIT .,P.RIVY <br /> j <br /> TI SPOSAL�I'IELD"" -'-'^CESSP00 /SEEPAGE-PIT' -OTHER- <br /> SEWAGE <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> .. Industrial x Cable Tool Dia. of Well Excavation ' <br /> Domestic/privateDrilled Dia;_$ of Well Casing <br /> Domestic/public Driven Gauge of Casing; <br /> X Irrigation Gravel Pack Depth of `Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other, <br /> SurfaceInformation�C�_esn out sand Inst. Z.iner <br /> *,. <br /> Geophysical ` Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> f H.P. <br /> Type of Pump f , <br /> 5 <br /> PUMP REPLACEMENT: ;k / State Work Done Replace existing Irrigation Turbine pump <br /> - State-Work.-Done <br /> PUMP :REPAIR:-- ". -- � /�T..�- <br /> - <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 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 my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING D NAL INSPECTION. <br /> SIGNED _ TA <br /> TITLE Partner <br /> 14 D�tAW- PLOT' PLAN 'ON RE FRSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> . ADDITIONAL COMMENTS: 4 <br /> PHASE II GROUT- I PECTION PHA I/ INAL iNSPECTIO <br /> t INSPECTION BY DATE INSPECTION BY DATE 0 <br /> 3/76 2M <br /> E-H 1426 Rev. 1-74 a- <br />