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- p SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> FOE 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 /> Hwy 132 to South on Koster- rt- on Blewitt "to over <br /> JOB ADDRESS/LOCATION overpass to mobile home CENSUS TRACT <br /> Owner's Name Vince Bogetti Phone 835-8972 <br /> Address P. 0. Sox 243 City Vernalis <br /> Contractor's Name I. J. Larsen Pumps, Inc. License # 276660 Phone 529y-2020 TYPE OF WORK (Check) : 'NEW WELL DEEPEN `RECONDITION_/ / DESTRUCTION <br /> PUMP INSTALLATION/ I PUMP REPAIR '/ / PUMP REPLACEMENT /x 7 <br /> r 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 /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/privateDrilled Dia. of Well Casing <br /> Domestic/public ._ Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout t. <br /> Disposal Others Other Information <br /> Geophysical Surface Seal Installed BY: <br /> ` PUMP INSTALLATION: Contractor % <br /> Type of Pump H.P. <br /> Pull and ins al <br /> PUMP REPLACEMENT: / State Work Done 1 h.p• subm W/PVC,'pipe <br /> k PUMP-.REPAIR: / / :-State Work-Done <br /> CDESTRUCTION OF WELL: Well Diameter Approximate Depth 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 GR.QVTING D=.A 41&TAL INSPECTION. <br /> SIGNED TITLE <br /> „ DRAW f0V PLAN ON REVERSE SIDE <br /> �•. FOR DEPARTMENT USE ONLY <br /> PHASE I _ _ <br /> DATE <br /> APPLICATION ACCEPTED'v9Y <br /> ADDITIONAL COMMENTS: <br /> PHASE .II .GROVT.;,INSPECTION PH4SF. III FINAL INSPECTION <br /> INSPECTIOIV'BY ' ° `: Y: <•� DATE INSPECTION BY DATE <br /> 3/7b 2M <br /> F E H 1426 Rev. 1-74 <br />