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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 9_4' 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATiiION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THISPERMIT 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 herein1described. 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 17041 Ketcham Ln. Linden - in d CENSUS TRACT <br /> I <br /> Owner's Name ARTHUR NEEDHAM Phone <br /> Address 17041 Ketcham Ln. 1 City L' de <br /> Contractor's Name GOEHRING PUMP & IRRIGATION INC. License 309031 Phone 727-5548 <br /> ti <br /> TYPE OF WORK (Check) ; NEW WELL/ / DEEPEN %/ RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other <br /> C <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY .h <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE. PIT OTHER <br /> PROPERTYLINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> L <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation � ! <br /> Domestic/private Drilled"' Dia. of Well Casing <br /> Domestic/public Driven `' `"'_ .—Gauge�of %Casing__ .: <br /> Irrigation Gravel,-ZackDepth ofGroutSeal <br /> Cathodic Protection- 1 Rotary! ', -Type, oQGrou.t <br /> Disposal Other � -Other Information. Y� <br /> Geophysical ' Surface Seal Installed'' <br /> PUMP INSTALLATION: Contractor <br /> 'Type -off Pump' , ,� .;. r. -.K: - H.P. <br /> PUMP REPLACEMENT: , X:k State Work Done re laced exi <br /> mersible <br /> PUP .REPAIR: `/ / State Work Done <br /> DESTRUCTION OF WELL. Well Diameter Approkii�6te`Depth <br /> }Describe Material and Procedure <br /> I hereby agree to comply with a1� laws and regulations of the San Joaquin Local Health District <br /> Land 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 9ROXWNG AND A FINAL! INSPECTION. <br /> SIGNED TITLE <br /> .(DRAW PLOT PLAN ON REVERSE SIDE <br /> �Ly����� <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: _ <br /> I GROUT INSPECTION <br /> PHASE IP E /F NAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 1177 . • 2m <br /> R N 1A9A Rav_ 1-74 -- - <br />