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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> . FOAiOFFIGE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> T"HI5 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> . gfaR _ ` (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 1 &.40. of -Durham Ferry, Rd on Koste Rd; CENSUS TRACT <br /> 507 wssz or AORTTU.- <br /> Owne-i's Name <br /> Bros, � <br /> Phone 209/835-5645 ' <br /> Address 30000 'So. gasson Road, city Trac <br /> Contractor's Name Western Well 1�1111in C6. Ltd. License # 25182 Phone 408/295.4332 <br /> fl <br /> TYPE OF WORK(Check): NEW WELL �� DEEPEN`/7 RECONDITION /7 * DESTRUCTION-�f <br /> PUMP INSTALLATION L�.PUMP REPAIR 97 PUMP REPLACEMENT <br /> Other• / / f <br /> DISTANCE TO NEAREST: SEPTICITANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL ^0 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Took. Dia. of Well Excavation � <br /> Domestic/private i Drilled " Dia. of Well Casing <br /> in <br /> Domestic/public t Driven Gauge of Casing <br /> Irrigation , Gravel Pack Depth. of Grout Seal j <br /> Cathodic Protection ► Rotary Type of Grout 1 <br /> Disposal ' Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type 6f Pump <br /> I H.P. <br /> ,PUMP REPLACEMENT: / / , State Work Done- ,� <br /> PUMP :REPAIR: IM7 State Work Done - <br /> ES;TRUCTION OF WELL: Well iameterF <br /> 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.o knowledge and belief. I •WILL CALL FORA -GROUT INSP ON <br /> PRIOR GROU INC AND A FINAL�INS ION. i <br /> SIGNED TITLE Vice President 2 27761 <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTME T USE ONLY <br /> PHASE I r•. <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION F E 1417-FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE <br /> 1 E H 1426 Rev. 1-74 I_7A ,u 1 <br />