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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS MFICE USE; 1601 E. Hazelton Ave: , Stockton, Calif. <br /> I Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S =id <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 1501 t�-.Shelt on M t' Wile East Eseal on-De!l ota ff NSUS TRACT 9'F-3 _LSD-ZZ <br /> f Owner's Name Clarence Kaw s Phone <br /> Address 25050 E. Snei_ton- Roadp Linden; Gal_i.f.j T City,--- <br /> Contractor's <br /> y, <br /> Contractors Name Fury ance Drillers,. Box b4, 7>inden, Ca]-if. License # 240107 Phone 931- L68 "'a <br /> � <br /> TYPE OFWORK (Check) NEW WELL L57 DEEPEN /? RECONDITION /7 "DESTRUCTION / j <br /> PUMP INSTALLATION _� PUMP REPAIR /_7 PUNP REPLACEMENT f_7 <br /> Other!/7 <br /> r , f <br /> E k <br /> DISTANCE TO NEAREST: SEPTIC TANK ' SEWER LINES PIT PRIVY <br /> "`SEWAGE DISPOSAL FIELV­ " CESSPOOL/SEEPAGE PIT OTHER ' I <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL . PUBLIC DOMESTIC WELL - <br /> INTENDED USE ,, , TYPE OF WELL �. CONSTRUCTION SPECIFICATIONS,..{ <br /> Industrial _,, 1" <br /> a i.. x . Cable�Too1 Dia. of Well E:ccavatian x0 ' + j <br /> x` Domestic/private I - Drilled Dia. of Well Casing 10 ' <br /> Domestic/public , ..' ,. # i jDriven Gauge of Casing: 1Q a <br /> _ Irrigation : ¢ "< Gravel, Pack Depth of Grout}Seal. b0 . <br /> Cathodic Protection ;r�. 'Rotary°---- - - - Type of Grout Iveet Cement } <br /> Disposal =~ l Other `� N Other Information ' <br /> GeoP y , <br /> ti �sical •-.....� � , ,, � � , <br /> Surf-ace" Seal .Irilhalled BY: <br /> PUMP INSTALLATION: Contractor Purviance Driller.s--, `. r <br /> Type of Pump .- , <br /> _ G��l�r�o�� at tni�aate. wi't-1 _advise _ � � H.P. <br /> PUMP REPLACEMENT: / State Work�D/o <br /> PUMP :REPAI-R• � <br /> rLj�Sta�te� Wor�Dones.,:� <br /> ES;TRUCTION OF WELL: Well Diameter Approximate Depth I; , . <br /> Describe Material and Procedure t <br /> I hereby agree to comply with all laws and regulations ofthe San Joaquin Local HealthfDistrict <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 HealthlDistrict 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 GROUTING AN FINAL!INSPECTION. <br /> SIGNED TITLE Partner <br /> RAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: i <br /> PHASE IJ GOUT INSPECTION PHA III F AL INSPECTION <br /> INSPECTION BYW 24ADATE '._ -- -7_5 INSPECTION BY ,DATE j <br /> 4 E B 1426 Rev. 1-74 <br /> ---�-_ .1_74- 2M A <br />