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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR 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 I YEAR FROM DATE ISSUED Date Issued72- <br /> (Complete In Triplicate) <br /> Application is .hereby made to the San Joaquin Local Health District for a permit to construct <br /> dnd/or install the work herein described. This application is made in compliance with San Joaquin i <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> O <br /> JOB ADDRESS/LOCATION .2 dile East Tully & 100 yds South • o6 ?ler - CENSUS TRACT D u—aQo-2-9 <br /> Owner's Name BLT Vineyards Phone <br /> Address 150 . Jacquelyn Way, Modesto City <br /> Contractor's Name puryiance Drillers, P. 0. Box 64,- Linden License # 240107 Phone '931-4468 <br /> Ca if. 95236 <br /> TYPE OF WORK (Check) : NEW WELL/ DEEPEN '/x/ RECONDITION /-7 DESTRUCTION /- ? <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT /- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL-FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial, x Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing j <br /> Domestic/public Driven Gauge of Casing i-• <br /> x_ Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other s• Other Information <br /> PUMP INSTALLATION: Contractor C$� <br /> Type of Pump H.P. <br /> =�s <br /> L <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: A / 4-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 tue t the best of my knowledge and belief. <br /> SIGNE TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEP NT USE ONLY <br /> PHASE I �. <br /> APPLICATION ACCEPTED BY DATE L <br /> ADDITIONAL COMMENTS; <br /> PHASE II GROUT INSPECTION PHASE II /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY _ '.�� DATE Z <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />