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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF .OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �rLJ 4 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedcJ <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 compliancekalth <br /> ith San Joaquini <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local District. <br /> 30B ADDRESS/LOCATION CENSUS TRACT • <br /> Owner's Name Walter Rore PhoneI <br /> Address 4255, P'aoi.fic Avenue, Stockton, Calif. City <br /> Contractor'sI <br /> NPurvance Drillers P.O.B ox 64 Lindea Cal L " ._ <br /> - - Name i <br /> - -- - -- � License ��24Q107 Phone 937-"68 � <br /> 95286 �I <br /> TYPE OF WORK (Check) :. NEW WELL /i/ DEEPEN '/—/ RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION /l/ PUMP REPAIR / / PUMP REPLACEME <br /> Other ./-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK 2501 SEWER LINES PIT PRIVY �'IC <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER j <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial X Cable Tool Dia. of Well Excavation ![4U if <br /> - - - -- <br />. Domestic/private Drilled Dia. of Well Casing l4" ]![ , <br /> Domestic/public Driven Gauge of Casing 3/1611 Plate <br /> i <br /> X Irrigation Gravel Pack Depth of Grout Seal none'. <br /> Other Rotary Type of Grout A <br /> Other Other Information P[ <br /> PUMP' INSTALLATION: Contractor Purviance DrillersII <br /> Type of Pump Pressure Turbine H,P. 60 <br /> PUMP REPLACEMENT. j_/ State Work Done <br /> PUMP 'tEPAIR: <br /> / / State Work Done 1� <br /> ,DFgTRUCTION 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. IThe above <br /> information is true to tnhbest of my knowledge and belief. � <br /> SIGNED TITLE Partner <br /> (DRAW PLOT PLAN ON REVERSE SIDIET ll <br /> FOR DEPARTMENT USE ONLY CC <br /> PHASE I ,f <br /> APPLICATION ACCEPTED .BY DATE . <br /> ADDITIONAL COMMENTS; au <br /> PHASE II GROUT INSPECTION PHASE III/ INAL NSPECTION <br /> INSPECTION BY DATE INSPECTION BY AT -,1 .-7J <br /> i <br /> .. . CALL FOR A- GROUT INSPECTION -PRIOR T4 GROUTING AND FINAL INSPECTION. � <br />