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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORIOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> 713477 APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. lz7f ' <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 /> 23001 E of Atkins Rd. �'` <br /> JOB ADDRESS/LOCATION 0' -N of Brandt Rd. 1� CENSUS TRACT <br /> Owner's game Pete Bregman Phone 887-3191 <br /> Address 6849 N. Cox Rd. City Lihden, Ca, <br /> Contractor"s Name Purviance Driilers License IR40107 Phone 931-4468 <br /> TYPE OF WORK (Check): NEW WELL &-7 DEEPEN/_7 RECONDITION /_7 DESTRUCTION f_7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR /-7 PUMP REPLACEMENT 17 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 751 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 0j <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL t PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation Oil <br /> Domestic/private Drilled Dia. of Well Casing all <br /> Domestic/public Driven Gauge of Casing 12Ua <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout 1 par Cemen <br /> san � <br /> Disposal Other Other' Information grout <br /> Geophysical Surface Seal Installed.-By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. •_ <br /> PUMP REPLACEMENT: J / State Work Done <br /> PUMP :REPAIR: /7 State Work Done <br /> ES•TRUCTION OF WELL: Well Diameter A Approximate Depth <br /> Describe Material and Procedure , <br /> I hgreby agree to. complj 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 TO GROUTIN A FINAL INSPECTION. <br /> SIGNED If TITLE <br /> artner <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 II FINAL INSPECTION <br /> INSPECTION BY DATE , INSPECTION BY DATE "7 <br /> w <br /> s E H 1426 Rev. 1-74 1-74 2M <br />