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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORIOFFICE USE: 1601. E. Hazelton Ave. , Stockton, Calif. <br /> -Telephone: (209) 466-6781 <br /> 11 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> I <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �r-� <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. 1.862 and the Rules and Regulations of the .San oaquin Local Health District. <br /> Z.`3Z�a �' Gf- 0 iSX(Ate 2s0_ ®7 <br /> JOB ADDRESS/LOCATION 1/2 Mi. S of Darhem Ferry Rd; 1/ Mi- E. of ChrismatltENSUS TRACT <br /> I Owner's Nave Marchese Farms Phone 209/835-$271 <br /> Address ' 631. Gaff ery Road Vernalis CA <br /> � City , � <br /> Contractor's Name Western Well Drilling Co., Ltd. License # 25182 Phone 295-4332 <br /> ' TYPE OF WORK (Check): NEW WELL 17 DEEPEN -/—[ RECONDITION /? DESTRUCTION f7 <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT <br /> a li Other — <br /> DISTANCE TO NEAREST: SEPTIC TANK -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 /> � <br /> Industrial �� Cable Tool Dia, of Well Excavation <br /> Domestic/privates Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge_of,CAsing.- _ <br /> lraigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> -_____Disposal, � Other Other Information <br /> Geophysical Surface Seal. Installed By: <br /> PUMP INSTALLATION: Contractor <br /> i�Type of Pump 11n H.P. <br /> d <br /> PUMP REPLACEMENT: ;/ / State Work Done <br /> PUMP +.REPAIR: / / State Work Done <br /> ES;T1UCTION OF WELL: :Well Diameter Approximate Depth <br /> !Describe Material and Procedure <br /> i. <br /> I hereby agree to comply with all laws and regulations of the San .3oaquin Local Health District <br /> k and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> F after completion of <br /> p my work on a new well I will furnish the San Joaquin Local Health District <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 WILT, CALL FORA GROUT INSPECTION <br /> PRIOR T ROUTIN A FINAL INSPECT N. <br /> SIGNED TITLE President <br /> &EMT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED -BY DATE77 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE•III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. -1-74 v22 <br /> - 1-74 2M <br />