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Y SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FM OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -IS <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED' Date' Issue d C7'=12- . <br /> (Complete In Triplicate.) Zoo�f <br /> Application is hereby made tol-the San Joaquin Local Health District for a .permit to construct <br /> and/or install the work hereiii 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 Distract: <br /> JOB ADDRESS/LOCATION 501 North Front Street, * Mile East Duncan Road CENSUS TRACT <br /> Owner's Name Mrs. B. R. Purviance Dba Linden Fater Service Phone 931-4468 <br /> f - <br /> Address P. 0. Box 642 Linden, Calif. 95236- city <br /> Contractor's Name Purviance Drillers, 1'_O.Box §4, Linden License # 240107 Phone 931-4468 <br /> lip <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION *7 DESTRUCTION /-7AL <br /> PUMP INSTLATION /—/ PUMP REPAIR / PUMP REPLACEMENT /b-T <br /> Other <br /> R w <br /> DISTANCE TO NEAREST: SEPTIC TANK 3001 SEWER LINES PIT PRIVY {7t <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/privateDrilled Dia. of Well Casing <br /> x Domestic/public ! Driven Gauge of Casing <br /> Irrigation t Gravel Pack Depth of Grout Seal 2501 <br /> Other 1 Rotary Type of Grout Neet Cement <br /> i Other .,.Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / J State Work Done 4 <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 e TITLE Partner <br /> ( PLOT PLAN ON REVERSE SID—ETFR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: = - <br /> PRASE IIG C P / INAL INSPE I <br /> INSPECTION BY ATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 /72 1M <br />