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SAN JOAQl3N LOC-" <br /> A HEALTH DISTRICT <br /> 70Wf 'F1L 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 3 y <br /> (Complete In Triplicate) <br /> Application is hereby made to the Salt 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 /> . .:... . <br /> rJ�-q 7-Cl [n} w <br /> JOB ADDRESS/LOCATION Off. Blewett Road next to I_5 !�` /v CENSUS TRACT i <br /> Owner's dame Vista Verde Farms Phone <br /> Address ' P.O. Box 90, Tracy, OA 95376 - City Tracy <br /> Contractor's Name Western Well Drilling Co., Ltd. License # 25182 Phone 295-4332 <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN -/7 RECONDITION /=77 DESTRUCTION /7 � <br /> PUMP INSTALLATION ;r/--PUMP REPAIR /� PUMP REPLACEMENT /7 E <br /> Other 1 I <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/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of CasingI -y --_�-^ t <br /> i Irrigation --` _ Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal ' Other Other Information <br /> Geophysical Surface Seal Installed B. : <br /> PUMP INSTALLATION: Contractor ;. <br /> Type of Pump ,vertical H.P. 125 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: <br /> /7 State Work Dane <br /> PES;TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> t <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 rnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them befo a putting..the. well in-use.. The above <br /> information is true to the best-of my knowledge nd b lief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR TING INSPECTION <br /> SIGNED TITLE President Se t/77 <br /> D W PLOT PW ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE--?'` <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> ^E H 1426 <br /> ` Rev. 1-74 1-74 2M <br />