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-c: 03 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO&+(OFFICE USE: 1601 E Hazelton Ave. , 'Stockton, Calif. <br /> ra"k- 30`ps, Telephone: (209) 466-6781 �l <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -7V 7j <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 Regulates of- the San Joaquin Local Health District'. <br /> 11 <br /> ,FOB ADDRESS/LOCATION Rd CENSUS TRACT <br /> Owner's Name Buck Merriman Phone <br /> Address-- - -2 1 West Ave. 134, `� City San 'Leandro l Ca <br /> Contractor''s.Name Furviance Drillers Drilling CO-License # 240107Phone 931-4468 <br /> TYPE-.OF WORK (Check):-NEW WELL-&7- -DEEPEN /7 RECONDITION /7T = DESTRUCTION /-7 — <br /> PUN? <br /> -j —PUMP INSTALLATION / PUMP REPAIR / J PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK /0j SEWER LINES PIT PRIVY � <br /> SEWAGE DISPOSAL FIELD ' CESSPOOL/SEEPAGE PIT -OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL . <br /> INTENDED USE TYPE OF WELL j CONSTRUCTION SPECIFICATIONS <br /> Industrial xx Cable Tool Dia. of Well Excavation. �r— <br /> �x Domestic/private Drilled ^ Dia. of Well Casing. 1511 <br /> Domestic/public Driven Gauge of Casing 10 age <br /> Irrigation Gravel Pack + Depth�of Grout.NSeal 0 <br /> Cathodic Protection-�--��---�-rRotary �-~ "--Type of Grout �'c-e=T1 <br /> Disposal. Other Other Information <br /> Geophysical ", � 'Aurface Seal Installed By - <br /> PUMP INSTALLATION: Contractor Purvija:nce Drillers P=p Cor <br /> Type of Pump Turb'Ezne H.P. <br /> PUMP REPLACEMENT: / / State Work Done ,;i s <br /> 4 <br /> PIE',REPAIR: /7 State Work Done <br />"", ESTRUCTION�OF _WELLi Well Diameter ` Approximate Depth <br /> Describe Material and Procedure €�' <br /> I hereby agree to comply with all laws and tegulatidns ofWN6 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 furAi'shf 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 /> PRIOR TO GROUTING, A INAL INSPECTION. <br /> SIGNED ,i.. TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) . -. <br /> FOR`BEPARTMENT USE ONLY <br /> PHASE i <br /> APPLICATION ACCEPTED BY, r. <br /> DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE I Ta INSPECTJON . '� IArr6 P INSPECTION <br /> INSPECTION BY DATE �, �. 7 ,t; INSPECTION. BY ATE --s <br /> r <br /> 1 E H 1426 Rev. 1-74 �' 1-74 2M <br />