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li SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> a: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, 7A <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> an is hereby made to the San Joaquin Local health District for a permit to construct <br /> ,stall the work herein described. This application is made in compliance with San Joaquin <br /> county'-!irdinance No. 1862 aid the Rules and Regulations of the San Joaquin Local Health District. <br /> JOE AD:DRESS/LOCATION East/ side Clements Road, North side Dead-end Brandi CENSUS TRACT <br /> a <br /> Owner's Name. Darwin 1ewis Phone <br /> Address 23709 E. Brandt Road, nodi, Calif. ,95240 City <br /> Contractor's Name Purvi.ance Drillers,Box 641T,indeniCalif.95236License # 240-107 Phone 931-4468 <br /> TYPE OF WORK (Check) : NEW WELL/_7 DEEPEN '/-7 RECONDITION /7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /i7 PUMP REPLACEMENT /7 <br /> Other /% <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL " PUBLIC DOMESTIC WELL }� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation U <br /> Domestic/pvate Drilled Dia. of Well Casing d <br /> Domestic/public Driven Gauge of Casing <br /> X Irrigation Gravel Pack. Depth of Grout Seal <br /> Cathodic Protection Rotary --"""Type-o1 Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> I <br /> PUMP REPLACEMENT: /x/ State Work Done Repair and replace original pump <br /> PUMP .REPAIR: /% State Work Done <br /> i <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 the well and notify them before putting.the..well in.use... The above <br /> informs on s tr he, est of my..knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR G Ti AL INSPECTION. <br /> SIGNED TITLE Partner <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> R DEP TMENT USE ONLY <br /> .I <br /> APPLICATION ACCEP DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION PIAS IW/FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 )�/�K <br />