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SAN JOAQUIN LOCAL -HEALTH DISTRICT <br /> FOS OFFICE USE: �` 1601 E. Hazelton Ave. Stockton, Calif. <br /> ' Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -,7r-771 <br /> THIS PERMIT EXPIRES 1 yEAR FROM DATE ISSUED S <br /> (Complete In Triplicate) Date Issued <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 wade in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> l Ilil.. t erogiis and - mile <br /> JOB ADDRESS/LOCATION "�-_--" -� <br /> We s t of Hewi t <br /> fInd... CENSUS TRACT <br /> ; <br /> Z <br /> Owner's Nam & J Donders Prone <br /> Address - - 16299N. ' Hw '2 _ m City Linden <br /> Contractor's Name Purviance Driller Lice�nge #240107 Phone 931-4468 <br /> TYPE OF..WORK._(Check). NEW_WELL DEEPEN. RECONDITION /7f---DESTRUCTION-/7-) <br /> PUMP INSTALLATION /-7 PUMP REPAIR /-7PUMP <br /> Other /% REPLACEMENT /'f <br /> y <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES-%. PIT PRIVY <br /> none SEWAGE DISPOSAL FIELD ! CESSPOOL/SEEPAGE PIT OAR <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrialx Cable Tool �' Dia. of Well Excavation <br /> Domestic/private Drilled 4 Dia. of Well Casing <br /> Domestic/public Driven '14. , Gauge of Casing <br /> Irrigation Gravel Pack... ' Depth of Grout Seal <br /> r �"�'"Cathodic-Protection Rotary � Type of Grout <br /> Disposal Other Other Information <br /> —Geophysical' J, Surface <br /> .—Seal Installed BY: <br /> PUMA' INSTALLATION: Contractor <br /> i <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: j/7 State Work Done <br /> State-Work=Done <br /> k, ES•TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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.jlaho4ledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING D INAL;14 SPEG'PION.4s <br /> SIGNED r <br /> -TITLEpartner <br /> D W` PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ` <br /> ..i . i•T `� DATE <br /> ADDITIONAL COMMENTS: <br /> Of <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION ' <br /> INSPECTION BY DATE INSPECTION BY DATE i <br /> H 1426 Rev. 1-74 (IF / <br /> �t h a { o c <br /> 1-74 2M <br />