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r SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFA CE«USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> -' Telephone: (209) 466-6781 .45 4 <br /> APPLICATION FOR WELL"CONSTRUCTION OR PUMP PERMIT Permit No. 3�(U <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued WP-5123 <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 Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 11it-N. Jathant & 1,9320 W. Elliot CENSUS TRACT <br /> Owner's Name LeBaron & Reolda -- Phone <br /> Address 2308 Cabrillo Circle, Lodi, Calif. 9524+ City <br /> Contractor's Name Purvianee Drillers, Box 64., Linden License # 210»109 Phone 931-4468 <br /> TYPE OF WORK (Check) : NEW WELL / .-&T DEEPER /_/ RECONDITION /-7DESTRUCTION /7 <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> (see map) SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial g Cable Tool Dia. of Well Excavation 16" <br /> Domestic/private Drilled Dia. of Well Casing 16H ,f <br /> Domestic/public Driven Gauge of Casing 3/16 piate <br /> X Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor Purviance Drillers <br /> Type of Pump Turbine H.P. 200 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <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 trueo t best of my knowledge and belief. <br /> SIGNED TITLE Partner <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE Z—z c z s <br /> ADDITIONAL COMMENTS: 70 <br /> PHASE II OROtq I SPE)CTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY _ DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M {{ <br />