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--- l --- -------- <br /> SAN <br /> ----_SAN JOAQUIN LOCAL HEALTH DISTRICT �t/ S <br /> 0W OFFICE USE: 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 <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 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 .3 Mile South LeRoy & .3 Nile East North Ripon RoadCENSUS TRACT <br /> Owner's Name Clifford Williams � G✓• 1 C A- Phone <br /> Address _ ���� � City <br /> Contractor's Name Purviance Drillers,P.O.Boa 64,Linden,Ga1if. License # 240707 Phone 931.4468 <br /> 9523t— =080000� <br /> TYPE OF WORK (Check): NEW WELL /i-7 DEEPEN/-7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION L-7 PUMP` REPAIR /-7 PUMP REPLACEMENT 17 <br /> Other / 7 <br /> DISTANCE TO NEAREST: SEPTIC TANK m .-e SEWER LINES PIT PRIVY r <br /> SEWAGE DISPOSAL FIELD i Mile CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS � <br /> Industrial z Cable Tool Dia. of Well Excavation 14" <br /> Domestic/private Drilled Dia. of Well Casing 1.4" <br /> ._— Domestic/public Driven Gauge of Casing 10 <br /> z Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout s <br /> Disposal Other �_ Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 411-71-7S <br /> Type of Pump P• •�� <br /> PUMP REPLACEMENT: j%/- State Work Done <br /> PW .REPAIR: _ /7_ State Work Done _ <br /> ,SES®RUCTION 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. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOGRQUTING FINAL INSPECTION. <br /> SIGNED TITLE Partner <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE Ilk/FINAL INSPECTION <br /> INSPECTION BY DATE _1 INSPECTION BY t4J&j±±4jaDATE .-- - -7 F <br /> ,a <br /> E H 1426 Rev,. 1-74 1-74 2M <br />