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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. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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"_. `MORADA' LANE �rdEST OF AWY OIITH IDE CENSUS TRACT <br /> Owner's Name CORTO PASSI FARMS INC. Phone <br /> Address 11292 N. ALPINE RD-. City STOCKTON <br /> Contractor's Name HENNINGS BROS. DRILLING CO.j INC. License # 290813 Phone --118 <br /> 3525 FEMDALB AVE., <br /> MUDBbTU <br /> TYPE OF WORK (Check) : NEW WELL /-�/ DEEPEN / / RECONDITION AL / _ <br /> _/ DESTRUCTION / <br /> PUMP INSTLATION REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / / ^" <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> tie <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS F , <br /> Industrial Cable Tool Dia, of Well Excavation 26" <br /> Domestic/private Drilled Dia, of Well. Casing <br /> Domestic/public Driven Gauge of Casing -SGA <br /> Irrigation X Gravel Pack Depth of Grout Seal _ :- -- <br /> Cathodic Protection X Rotary Type of Grout <br /> Disposal Other Other Information SLAB-BY OWNER <br /> Geophysical Surface Seal Installed By: �. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> _ r <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 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 of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL <br /> y— - - B "" IN�GECT$SIGNED <br /> INC'. BY TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE i ,i <br /> E H 1426 Rev. 1-74 �� 1177 '' <br />