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i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR'OF`fICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone (209) 466-6781 <br /> Od 00 APPLICATION FOR WELL CONSTRUCTION"-OR PUMP PERMIT Permit No. Z j 5 -7 <br /> qq5 75 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 4-/ 3/ Z <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 /> JOB ADDRESS/LOCATION South side ofof Var Allen CENSUS TRACT - <br /> Owner's Name Gus Vander Yeu1'en -Phone 838-2606 <br /> Address P0234 Avena City 7sc. .lon <br /> Contractor's Name John Pan`=ro License # 12^7-14 Phone P,',R-7570 <br /> 11935 n r_ en, :Escai,) <br /> TYPE OF WORK (Check) : NEW WELL/x/ DEEPEN RECONDITION RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 90 SEWER LINES _ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS s <br /> Industrial x Cable Tool1 x10 Ga. c--reductor <br /> Domestic/private Drilled Dia. of Well Casing 10 x10 Ga. Ka -w2 i <br /> Domestic/public Driven Gauge of Casing -4)• <br /> Irrigation Gravel Pack Depth of Grout Seal 50 <br /> x Other d.alry b.5rr. Rotary Type of Grout CementinE <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <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 <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. <br /> SIGNED TITLE 0 wn;�r- Contractor <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE , <br /> ADDITIONAL COMMENTS: <br /> PHASE I GROUT INSPECTION PVA IWgM INSPECTION <br /> INSPECTION BY d 51 DATE 27- INSP ION BY � Zd--2DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 ' 4/72 1M. <br />