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J <br /> SAN JOAQUIN LOCAL HEALTH- DISTRICT } s. <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 Z$' <br /> ,, _ (Complete In Triplicate) - - , r. ' <br /> Application is hereby made to the San Joaquin Local Health District for a permit Po 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 /> 3i <br /> JOB ADDRESS/LOCATION __NW! cggner. S-areokles a Wgodward CENSUS TRACT <br /> Owner's Name Boger Bianc ' Phone <br /> AddressVer <br /> City t <br /> Contractor's Name S•tanislaus Pump & Machinery Corp.. License # A290355 Phone 5221027. <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/y/ DEEPEN -/—/ RECONDITION /-7 DESTRUCTION /- <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /7 ; <br /> Other /_7 <br /> DISTANCE T.0 NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELD, PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF-WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well. Excavation <br /> - Domestic/private i, Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation 9 . Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal ;' Other Other Information <br /> Geophysical H Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - -- H.P. L <br /> PUMP REPLACEMENT: . / i;/ State Work Done <br /> li E <br /> PUMP .REPAIR: / / 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 F <br /> after completion of 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 b lief. I WIL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GRO ING AND NAL INSPECTION. � <br /> SIGNED TITLE <br /> (DRAW40T PLAN `ON 9RSE SID E <br /> * � FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: ' <br /> PHASE 11 GROUT SPEC_T_ION PHASE II FI INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 7 <br /> II 1 k <br /> d <br /> 3/76 2M <br />_..... E H 1426 Rev. 1-74 j ' �'"�'? � � .. <br />