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- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FX OFFICE SE: 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 , :� _ I <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin- Local Health Distract 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 /> [860.t €_ rte• A-v-4N ; 6,?t^ r70_ a8 <br /> JOB ADDRESS/LOCATION •2 Mile North Comstock & ..4,10ile East Duncan CENSUS TRACT <br /> Owner's Name Robert C e?tam a Phone <br /> Address .. ].8 503. E. Comstock Road, T,inden,-Ca3,if. 95236 - City <br /> Contractor's NamePurviance Drilters,P.O..Box 64,Linden,Calif.. License #2+0107 .!Phone 931-446r, i <br /> 9523b— <br /> i <br /> TYPE OF-WORK :(Check):=- NEW WELL /=7 7 EEPEN fes" CONDITION /__ 'DESTRUCTION,; 7 F <br /> PULP INSTALLATION / / PUMP REPAIR / 7 _PUMP"REPLACEMENT xf 7 <br /> � 3 <br /> Other /� , rl ^ <br /> DISTANCE TO NEAREST: SEPTIC,-.TANK 75 SEWER LINES 75 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 75 CESSPOOL/SEEPAGE PIT OTHER <br /> £PROPERTY+ LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL— G <br /> INTENDED USE. '_. TRIPE OF WELL CONSTRUCTION SPECIFICATIONS - <br /> IndustriaT% /ia Cable Tool Dia. of Well Excavationsang <br /> I a Domestic/private rs ''r Drilled Dia. of Well Casing Inst. - ner <br /> Domestic/public. Driven Gauge of Casing <br /> Irriga:tiQn'__--" Gravel Pack orftepth of Grout Seal A,- I <br /> Cathodic;Ixotection Rotary AType of Grout' AlQ. 1 y, <br /> Disposal/ Other Other Information <br /> Geophy= cal P,6rface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> A { Type of Pump H.P. !r <br /> PUMP REPLACEMENT: /X1 State Work Done Install customer 1. HP Submersible -, <br /> PUMP !_REPAIR: • F /7 State Work Done - - <br /> ,RES TRUCTION OF WELL: Well Diameter - Approximate Depth <br /> Describe Material and Procedure i <br /> i I hereby.,-agree .to-comply-w th-all—laws-and- regulations•of-the-San-Joaquin Local- Health Diatxict <br /> and the State of' California'pertaining-to or reguYat.ing well construction. Within FIFTEEN DAY5 <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 /> M information is true to the best. of -my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AN FINAL INSPECTION. <br /> / � x ; � s is � '' �"` <br /> SIGNED •-1� TITLE Partner <br /> ( 4 (DRAW PLOT PLAN ON REVERSE SIDE <br /> 41 1 ► i ,''" FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 71f: <br /> DATE ,� zzz/7 <br /> ADDITIONAL COMMENTS: `��T si�i a�•'`' <br /> PHASE II GROUT INSPECTION PRASE III/FINAL INSPEC24ON <br /> f <br /> INSPECTION BY I I V, DATE INSPECTION BY DATE 6 <br /> IV 11 <br /> i <br /> E H 1426 Rev. 1-74 1-74 2M <br />