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4 _ <br /> SAN JOAQUIN LOCAL HEALTH. DISTRICT +. <br /> r0E OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209)466-6781 1 <br /> - ` APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued A-.29 <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 Ru es and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 550' South Hwy 26 and Li'1_e West Iiiurray Road CENSUS TRACT <br /> Owner's Name ' Join Podesta Phone <br /> Address _ 7. 5560. East Hwy 26, T„inden, C-0 if. 9'5236 City <br /> Contractor's Name Parvia nee DrMers F'.O.Fox 6 - - � A <br /> 4,�,inden,Ca7 a_f: Licensee �� Phone <br /> 9523 I <br /> C1't <br /> TYPE- OF WORK (Check) --�-N W LLQ/ --'DEPEiy / /==RECO }I°fION '/ -'� RESTRCT-IONS/ T9- �= = -� <br /> PUMP INSTALI:ATION /X/`PUMP.­REPAIR-1-/7-PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 601. SEWER LINES 60 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 60 CESSPOOL/SEEPAGE,�PIT OTHER Irrigation 1,`e1 <br /> .' PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> 50 <br /> /INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> .Industrial x Cable Tool-----�Ilia,. df Wei--Excavation <br /> 7x -,Domestic/private, Drilled___T""f- <br /> Domestic/public Driven Gauge of "Casing 12 Q <br /> .-,Irrigation Gravel Pack Depth of Grout Seal 12" Conductor - ' G <br /> 'Cathodic Protection Rotary Type of Grout 2 parts sand to 1 part cement_ <br /> Disposal Other Other Information;_ <br /> Geophysical '� Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor 'Furvian?ce Dril.l.ers <br /> Type of Pump,,' Submersible - - --- H.P. 1% <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State. Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree. to comply_-with rall•,laws and regulations of the 'San Joaquin Local Health District <br /> .t is y } <br /> and the State -ofvCalifo.rnia -pertainingIt'o or regulating well'construetion. Within FIFTEEN DAYS <br /> after completion of my work on anew well, I will furnish the San Joaquin Local Health District a i <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" eli:ef. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR,-TO� GROUTI D"A- I'INAL'4-INSPECTION. <br /> SIGNED TITLE Owner r <br /> (DRAW <br /> -'PL T PLAN 'ON RE 9RSE .SIDE); <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE 'y <br /> APPLICATION ACCEPTED BY . <br /> ADDITIONAL COMMENTS:. - <br /> PHASE II GROUT INSPECTION PHA4E. /FINAL INSPECTION__7--\ <br /> INS ECTION�BYz- �� . DATE I SPECTION BY ,c 41ta , DATE � 2iFo <br />