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N JOAQUIN LOCAL HEALTH DISi'RIC <br /> FOR+OFFICE USE: 16u_ E. Hazelton Ave. , Stockton, Caiif, <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.-'-7f--7--3J' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Ji I Xew <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health DisericL 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 223' North Hwy 26 (16 533 E. Hwy 26) CENSUS TRACT <br /> Owner's Name Rat ph Croce Phone <br /> Address 16533 H. jiyvv 26, Tinden, Ca' if. 55236 City <br /> Contractor's Name Purviance Drillers,F.O,~ox 64,Tinden,Cn1if. License # 24010') Phone 931-4468 <br /> 95236 <br /> TYPE OF WORK (Check) : NEW WELL ACS DEEPEN /-7 RECONDITION /-7 DESTRUCTION / \ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other [—/ <br /> DISTANCE TO NEAREST: SEPTIC TANK 58" SEWER LINES PIT PRIVY W <br /> SEWAGE DISPOSAL FIELD 51, CESSPOOL/SEEPAGE PIT OTHER W <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial x Cable Tool Dia. of Well Excavation 811 <br /> x Domestic/private Drilled Dia. of Well Casing it <br /> Domestic/public Driven Gauge of Casing i2 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout 1part cement 2 pari;s sand o t <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DES•TRUCTION OF WELL: Well DiameterApproximate Dept / �Q <br /> Describe Material and Procedure , _ <br /> I hereby agree to comply with all(laws and regulation4 of the San Joaq n Localj1ealth istrict <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 knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> 'RIOR TO GROUTING AND FINAL INSPECTION. <br /> SIGNED TITLE <br /> 1'a rtner <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ` DATE j <br /> ADDITIONAL COMMEN S: <br /> P Ij GROUT INSPECTIO PHA II /FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE n <br /> E H 1426 Rev. 1-74 <br /> i-74 'M <br />