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FOFrQFFICE USE: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED' <br /> A EComplete In Triplicate) Date. Issued�'/�7�' <br /> pplication is hereby made to the San Joaquin Local- Health Dlattict for a permit to construct <br /> and/or install the work herein described. This gPPlication 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 : 223' North Zwv 26- (76533 E. H 26 <br /> CENSUS TRACT <br /> Owner's Name Ral_Dh Croce <br /> Phone <br /> Address 'x6533 E. 26 Linden` Cay if. 9.5236 City <br /> Contractor's Name Purviance Drillers P.O.Boxi6Linden Ca if. License <br /> 2J+OI©'7 Phone 31- 68 <br /> 2 <br /> TYPE OF WORK (Check): NEW WELL ? DEEPEN -/ " RECONDITION F7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENY <br /> Other /% _ +N <br /> DISTANCE TO NEAREST: SEPTIC TANK Sgt SEWER LINES-:* <br /> SEWAGE DISPOSAL FIELD 581 CES 'SEE PRIVY rr ,, <br /> SPOOL/SEEPAGE PIT _ OTHER <br /> r- W , <br /> PROPERTY LINE PRIVATE DOMESTIC'Wh' -L' ,PUBL £- +WELL <br /> DOMESTIC <br /> INTENDED USE TYPE OF WELL CO. NSTRUCTION SPECIFICATIONS <br /> Industrials Cable Tool Diaof Well Excavation----97r' J� <br /> `x Domestic/private Drilled <br /> Domestic/public n Dia. of Well Casing <br /> Irrigation <br /> DrivenGauge-of Casing <br /> 72 <br /> Gravel Pack Depth.of Grout Seal 501 <br /> Cathodic Protection Rotary Type of Grout' -1 rt cement/2 xts sand r© t <br /> .Disposal ' Other Other��Information <br />.Geophysical ��� Surface/Seal installed B <br /> : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP- REPLACEMENT:� /% State Work Done } <br /> PUMP REPAIR: L7 State Work,Done-'""" —~ ___ F <br /> E&TRUCTION OF WELL: Well Diameter <br /> Describe Material and, Procedure Approximate Dept _.L-�Q <br /> I hereby agree to comply wit "h all aws an regulati� of t e San Joa <br /> and the State of California perta ing to or regulating well construction. WitLocal ealth i t ict <br /> AYS <br /> after completion of my work on a new well, I will furnish.the Sac: Joaquin Localhin Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting.. the .well in.uee.. <br /> ab e <br /> information is true to the-best of. my.knowledge and belief. eov <br />.31 OR TO GROUTING AND FINAL INSPECTION. I WILL CALL FORA GROUT INSPECTION <br /> SIGNED <br /> TITLE P e ' <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I # E'er FOR DEPARTMENT USE ONLY . <br /> APPLICATION ACCEPTED BY n �3.. " 'r• 5'' <br /> ADDITIONAL COMMEN : DATE <br /> P I GROUT INSPECTIO <br /> INSPECTION BY DATE ► 's. INSPECTION BY <br /> FINAL INSPECTI <br /> DATE p e <br /> E H 1426 Rev. 1-74 <br /> 1-74 2m <br />