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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORtOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> w <br /> - .THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued <br /> Appli <br /> p--Ji (Complete In Triplicate) <br /> cation is hereby made to the San Joaquin Local Health Disttict. for a permit to construct <br /> and/or install the work herein described. This application is 'made in compliance with San Joaqu: <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION I Mi.No. of Durham Ferry Rd on Koste Rd; CENSUS TRACT <br /> 50! sT, or Aoste 7d. <br /> rog.•1 B <br /> Owner's Name MaciPhone 209/835-5645 <br /> Address 0000 So. Kasson Road, City Tracy <br /> 1 • <br /> Contractor's Name Western Well grilling Cm., Ltd. License # 25182 Phone 408/295-4332 <br /> .. .. .� <br /> TYPE OF WORK(Check): NEW wELL L_T DEEPEN /7 RECONDITION /_7 DESTRUCTION L7 <br /> PUMP INSTALLATION /7 .PUMP REPAIR XF PUMP REPLACEMENT L7 <br /> Other•11-7 i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGEiDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOL MESTIC WELL PUBLIC DOMESTIC WELL ^� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS S <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private i Drilled Dia. of Well Casing 4, <br /> Domestic/public t Driven Gauge of Casing \ <br /> Irrigation i Gravel Pack Depth of Grout Seal <br /> Cathodic Protection ► Rotary Type of Grout <br /> Disposal t Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type °f Pump H.P. <br /> PUMP REPLACEMENT: L/ State Work Done- - <br /> PUMP `.BEPAIR: State Work Done <br /> )ESR UCTION OF WELL: Well Diameter Approximate Depth _ <br /> Describe. Material and Procedure p <br /> L hereby agree to complywith all laws and regulations of the San Joaquin Local Health District <br /> in.d 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 /> TELL DRILLERS REPORT of the well and notify them before putting..the. well in.use.. The above <br /> [reformation is true to the best•o knowledge and belief. I •WILL CALL FORA GROUT INSP ON <br /> RIOR GROU ING AND A FINALiINS ION. <br /> 'IGNED TITLE Vice President P"42127/7 <br /> (D W PLOT PLAN ON REVERSE SIDE <br /> 'RASE I FOR DEPARTMtt USE ONLY <br /> ►PPLICATION ACCEPTED BY DATE r� <br /> ►DDITIONAL COMMENTS: <br /> PHASE II GROUT INSP CTION P E I l FINAL INSPECTION <br /> NSPECTION BY DATE INSPECTION B DATE ,Zo 7� <br /> E H 1426 Rev. 1-74 <br />