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SAN JOAQUIN LOCA F } <br /> LIHEALTH DISTRICT <br /> FO&IEF] ICE .USE: <br /> '- I/ <br /> 1601 E. Hazelton Ave. , Stockton, Calif. i <br /> Telephone: (209) 466-6781_ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,;1 - <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /.j /g--/7 t� <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 trade in compliance with San Joaquin <br /> -County Ordinance No. 1862mand the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 14175 E. Highway #26, Linden: California _ CENSUS TRACT � <br /> Owner's Name LARRY .CELLE Phone 931-1800 <br /> Address "` <br /> P. 0, Box 187 City Linden <br /> Contractor's Name License # Phone <br /> ' _ _ DESTRUCTION <br /> TYPE OF.WORK (Check): NEW WELL -/-T DEEPEN '/-7 RECONDITION /7 � <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT I7 <br /> s . <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 50 . SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <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 NJ <br /> Irrigation Gravel Pack Depth of Grout Seal �. <br /> Cathodic Protection Rotary Type of Grout 1 <br /> i Disposal Other Other Information <br /> Geophysical 'Surface Seal Installed By: <br /> a G <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> 4 <br /> PUMP REPLACEMENT: / ! State work Done �y <br /> PUMP-,.REPAIR:F a /-7 -State Work-Done" Ft <br /> ES;TRUCTION OF WELL: Well Diameter 12 inches Approximate Depth 350 • <br /> Describe Material and Procedure Spin 'to wi4 ,'n Os oplLe m < s� <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 DRILLS S REPORT of the well and notify them before putting the-well in-use.. The above <br /> informatiojd is true to the-best•of my.knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO OUTING INAL INSPECTION. <br /> TITLE Owner <br /> SIGNED <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE Ip <br /> APPLICATION ACCEPTED BYNo. —� DATE /' 4 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - <br /> t %E H 1426 Rev. 1-74 1-W 2M <br />