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r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7z IT6 <br /> THIS PERMIT EXPIRES i YEAR FROM DATE 'ISSUED Date Issued Q-•3 0- 7 U <br /> (Complete 'ln Triplicate) <br /> Application is hereby de 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 x6228 E. Cop oropolis Road CENSUS TRACT ' <br /> Owner's Name John Paoletti Phone ' <br /> Address _ 16229 E. Coppoperolis Road,, Linden '° Cit <br /> - Y <br /> Contractor's Name Purviance Drillers, P.O.Box 64_p Linden License # 240107 Phone 931-x,.4.68 <br /> TYPE OF WORK (Check) : NEW WELL I / DEEPEN A7 RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR '/—/ PUMP REPLACEMENT /x_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 1001 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial. x Cable Tool Dia. of Well Excavation Dee n n <br /> x Domestic/private Drilled Dia. of Well Casing 8" m <br /> Domestic/public. Driven Gauge of Casing 16 • <br /> IrrigationGravel Pack -"Depth of Grout Seal <br /> Other Rotarye <br /> 'Type of <br /> Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. O I <br /> PUMP REPLACEMENT: /�/ State Work Done install eustomer pump � ' <br /> PUMP REPAIR: / / State Work Done f <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 t est of my know dge and belief. II <br /> SIGNED ~} TITLE 1 <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> s <br /> FOR DEPARTMENT USE ONLY i <br /> PHASE I __ �, � <br /> APPLICATION ACCEPTE41NSCTION <br /> DATE <br /> ADDITIONAL COMMENTS <br /> PHASE S ION P SE I FINAL INSPEC ION ' <br /> INSPECTION BYATE _ - INSPECTION BY DATE <br /> CALL FOR A GROUT PRIOR TO GROUTING AND FINAL INSP ON. <br /> E H 1426 4/72 IM CQ� + <br />