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SAN JOAQUIN,LOCAL HEALTH DISTRICT <br /> FOf.:O1FICE USL': 1601 E. Hazelton Ave.., Stockton, Calif. <br /> Telephone: ' (209) 466-6781 <br /> ELAPPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT. EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7 �- <br /> (Complete In Triplicate) <br /> Application is hereby.made to the San Joaquin Local Health District for a permit..66 construct <br /> and/or install the work herein described. ' This application is made in compliance with San'Joaquin <br /> Coutlty Ordinance No. 1862 and the Rules and Regulatiosts of the San Joaquin Local. Health >District. <br /> JOB ADDRESS/LOCATION 690' South Pr$sher Rd, an East side'M!&j%y-Ril•-�� CENSUS TRACT 105-100- <br /> Owner's Name J-oe Dondero ,;1, Phone <br /> t� r <br /> Address _ 16299 `E,. H 26, Tinden, Calif.. 95236 /'N City, -' <br /> Contractors Name Purviance Dri1.?ers, Dox els, <br /> Linden, Calif.if Licease.,#,,."240j017' Phone <br /> TYPE OF WORK (Check) : NEW WELL /-37 DEEPEN -/-' <br /> RECONDITION /_/ DESTRUCTION /_7 IJ <br /> F PUMP INSTALLATION / / 'PUMP REPAIR/ / PUMP REPLACEMENT /_ <br /> Other -/ / <br /> DISTANCE TO NEAREST: SEPTIC TANK �_ SEWER LINES PIT PRIVY 1 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PITT }}' ::`' ' OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial xCable Tool r Dia. of Well ;Excavation 811 <br /> x Domestic/private Drilled 1- Dia. of Well 'Casing 81 i <br /> Domestic/public Driven .>Gauge of Casing 1p �. <br /> Irrigation Gravel Pack r-.%, Depth of Groat Seal ;: p. <br /> Other Rotary r Type of Grout neet Cement____7_-d <br /> Other r' Other Information 12!1 Conductor pipe for . z � <br /> PUfiT INSTALLATION: Contractor ' Purvience DAllers ] <br /> Type of Pump 6ubaersible H.P. 3 <br /> PUMP REPLACEMENT. / / State Work Done) FJ <br /> State ,WorkDone'- ,- _ <br /> ,DFRTRUCTION OP WELL: Well Diameter _ Approximate Depth <br /> iat <br /> Describe Materl and Procedure <br /> I -fiereby 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 riew 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 knowledgeand belief. <br /> c <br /> SIGNED X i1 ` TITLE Partner <br /> D����(DR�AWPLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY r <br /> PHASE I <br /> ; .APELIGATI-ON ACCEPTED .BY { �l ] <br /> DATE <br /> r.-!ADDITIONAL -COMMENTS: : <br /> PW.E.IIAGROUT INSPE TION. ; PHPAE III F AL INSPECTION <br /> INSPECTION BY DATE 6-] INSPECTION BY <br /> - --CALL-FOR-'A-GROUT-INSPECTION-PRIOR TO GROUTING AND .FINAL-INSPECTION. <br /> E H 3.426 5/731M i <br />