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*- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF�;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76-Cpe'i w <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 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 38• a Plymouth Rd. CENSUS TRACT <br /> Owner's Name Theo Lee FryPhone ' 463 702 <br /> Address P32 Plymouth Rd. City " Stockton] <br /> Contractor's Name Owner Licensee : _ Phone63 1302 <br /> TYPE OF WORK (Check) : NEW WELL jft DEEPEN /7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR/_7 PUMP REPLACEMENT / f <br /> Other El <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 61 ft. - PIT PRIVY <br /> SEWAGE DISPOSAL FIELD I CESSPOOL/SEEPAGE PIT OTHER '. <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL ' PUBLIC DOMESTIC WELL Q <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _ Industrial -- . . - -Cable Tool - Dia. of Well Excavation 10 inch � ! <br /> ** Domestic/private • Drilled Dia, of Well Casing 5 inch N ' <br /> Domestic/public Driven Gauge of'-Casing. Class- 1701 plastic <br /> Irrigation Gravel Pack Depth of Grout Seal 5Q <br /> Cathodic Protection + Rotary Type of Grout o• <br /> Disposal Other Other In€ormation ' <br /> QQMent <br /> Geophysical Surface. Seal Installed By: <br /> PUMP INSTALLATION: Contractor Owner <br /> Type of Pump Submersibla H.P. 1 <br /> PUMP REPLACEMENT: . / • state Work Done <br /> PUMP ,REPAIR: /7 State Work Done Vlzo� - <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 patting. 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 G UTING"AND A.I'INAI� I11111ECTION.. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> - FOR DEPARTMENT USE ONLY .--- -- <br /> PHASE I : <br /> APPLICATION ACCEPTED BY DATE b <br /> ADDITIONAL COMMENTS: C, t - <br /> PHASE II GRO INSPE N PHASE III AL IN ECTI <br /> INSPECTION BY DATE INSPECTION BY DATE 3-� •"1"{ <br /> E H 1426 `Rev. 1-744775 2M <br />