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�.' .�..-mac . • � L � '�� <br /> SAN JOAQUIN LOCAI, HEALTH DISTRICT <br /> FOR OFFICE USE., 1601 E. Haielton Ave. , Stockton, Calif./ <br /> .- 6 <br /> Telephone: (209) 466781 ' <br /> E j- 17APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. i63, <br /> THIS PERMIT EXPIRES "l YEAR .FROM DATE ISSUED Date Issued8.; <br /> (Complete In-Triplicate) <br /> Application is' bereby made to the San Joaquin Local Health District for a permitto 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 54.01 ,4est rurviarce St. 1751 North .Front St CENSUS .TRACT OQt-�Op �3 <br /> f , <br /> Owner's Name" Paggio_Bros. Phone <br /> Address 5268 R. Duncan Rd. ;Sinden Cs? if. ,,952 6 City <br /> Contractor's Name Furviance Dr-,i <br /> Lers P,G,Box 64 Iincien Calif. License �� ?JO�D7 Phone 931,-4468 <br /> 95236 <br /> TYPE'-,OF-WORn(Che-tk): NEM--WELl:=-/ /— DEEPEN 'f—REC(3N 3 PION=/ c%y-DE5TWUCTIdYv-/ - - <br /> j PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /x7 �. <br /> # Other09 <br /> } DISTANCE .TO NEAREST: SEPTIC TANK j rile SEWER LINES PIT PRIVY <br /> 'SEWAGE DISPOSAL FIELD j miie CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY L LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC•WELL <br /> INTENDED-USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial X Cable Tool Dia, of Well Excavation Existing 1211 loll finer <br /> Doestic , rivate �. .. Drilled- Dia, of Well Casing to instar 8'� Einer. ; <br /> Domestic/public Dr iven Gauge of Casing <br /> zx.-.` Irrigation �' y ` Grhvel-Pack Depth of Grout Seal ` <br /> Cathodic�Protection Rotary Type of Grout <br /> : ( �T �S <br /> j Disposal " Other Other Information <br /> J`t. Geophysical --� ,. -, !y;` Surface Seal Installed By: <br /> _PUMP INSTALLATION: Contractor , <br /> Type of Pump ,c- - t. H j?. ] - <br /> + PUMP REPLACEMENT: /x/ State Work Done —I-nstal,1- customer 30- HP Tur-;Dine T X <br /> PUM REPAIR:.. / ./ .. State .o.rk_Done.___ <br /> DES-TRUCTION OF WELL: Well Diameter e Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with a11, 1aws 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 t�y work on a new well, I will furnish the San Joaquin Local Health District a <br /> t WELL DRILLERS REPORT of the well and notify them before putting the well in use. The abode <br /> information is true .to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> I. PRIOR TO GROUTING NAL INSPECTION. <br /> SIGNED TITLE Owner <br /> 'KDRAw PLT PLAN 'ON REVERSE SIDE) : "I <br /> f FOR DEPARTMENT USE ONLY <br /> PHASE I ff - _. <br /> APPLICATION ACCEPTED"BY /I �t .ter--- DATE <br /> 4 <br /> ADDITIONAL COMMENTS: _Z�4 <br /> PHASE II GROUT INSPECTION PHASE NAL INSPECTrION� <br /> INSPECTION' BY DATE INSPECTION BY DATE "f <br /> E H 1426 Rev. 1-74 <br /> ce.� �L� �7 '. <br />