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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> =• <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 Issued6� 7 7 <br /> (Complete In Triplicate) .01 <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 3737 North Duncan Road CENSUS TRACT <br /> Owner's Name Bill J. Purviance Phone <br /> Address 3737 North Duncan Road City <br /> Contractor's NamePurviance Dril ers,r.G,Lox 6k T.inden,Calif. License # 24.01037 Phone 933__4468 <br /> 95236 <br /> TYPE OF WORK (Check) : NEW WELL/_7 DEEPEN -/x RECONDITION /X7 DESTRUCTION /7 <br /> PUMP INSTALLATION I / UMP REPAIR/ / PUMP REPLACEMENT A7 <br /> Other .. — <br /> DISTANCE TO NEAREST: SEPTIC TANK S WER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FI D CESSPOOL/SEEPAGE PIT OTHER v <br /> PROPERTY LINE - P VATE DOMESTIC WELL PUBLIC DOMESTIC WELL G, <br /> INTENDED USE TYPE OF WE CONSTRUCTION SPECIFICATIONS v. <br /> Industrial x Cab Tool Dia, of Well Excavation <br /> x Domestic/private Dr led Dia. of Well Casing <br /> Domestic/public D ven Gauge of Casing <br /> Irrigation avel Pack Depth of Grout Seal <br /> Cathodic Protection otary Type of Grout <br /> Disposal Other Other Information Install 811 l iner in. exi- sti <br /> Geophysical Surface Seal. Installed By: 1-011 Drell_ <br /> 1 bee n 10" & 8" Casing with nee�t cement <br /> PUMP INSTALLATION: Contr for <br /> Type f Pump H.P. <br /> PUMP REPLACEMENT: /x/ State Work Done Reinstall- Dome <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 nest of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING FINAL INSPECTION. <br /> SIGNED TITLE <br /> , DRAW`,PL T PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Ii `- <br /> APPLICATION ACCEPTED BY �� DATE a 7 <br /> ADDITIONAL COMMENTS: -- <br /> PHASE II GROUT INSPECTION P /F AL INSPECTIO <br /> INSPECTION BY DATE �T INSPECTION BY DATE <br /> W <br /> E H .1426 Rev. 1-74 <br /> 3/76 2M <br />