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" SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 0-FO 'PICE USE. 1601 E. Hazelton Ave. , Stockton, Calif. G <br /> Telephone: (209) 466-6781 } <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�Y <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) / 8`-/-a ^07 i <br /> Appliedtion is hereby made to the San Joaquin Local Health District fatea permit to construct <br /> and/or install the work herein described. This application is shade in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> SS'S 5 S • [z.44-cE ra-r-0- <br /> JOB ADDRESS/LOCATION 501 West Kaiser Road & 3/4 Mile N. Mariposa Road CENSUS TRACT <br /> Owner's Name Tony Sanches Phone <br /> 5 <br /> Address 1.8 West Robinhood Drive, Stockton, Cal-if. City <br /> Contractor's Name Purviance Drijlers,P.O. Box 64 Linden,Cal,if4,icense # 240107 Phone 931-4468 I <br /> TYPE OF.,WORK (Check): NEW WELL /7 DEEPEN RECONDITION "Jx_7 DESTRUCTION -17 -- <br /> PUMP INSTALLATION /—/ PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK mile SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD miles CESSPOOL/SEEPAGE PIT OTHER U <br /> y <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 n <br /> Domestic/private drilled Dia. of Well Casing I t 2" TJney <br /> Domestic/public Driven Gauge of Casing o88 Na' i <br /> x Irrigation Gravel Pack Depth of Grout Seal _. <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By <br /> PUMP INSTALLATION: Contractor _ <br /> Type of Pump _ H.P. <br /> PUMP REPLACEMENT: j_/ State Work Done <br /> PUMP !REPAIR: /_7 State Work Done ' <br /> PES:TRUCTION OF 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 -6 <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 ANR A FINAL INSPECTION. <br /> SIGNED TITLE Partner <br /> (DRAW PLOT PLAN ON REVERSE,. SIDE <br /> - - OR DJEPARTMENT,USE ONLY - - <br /> PHASE I - <br /> APPLICATION ACCEPTED BY DATE /le/77 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PRASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE /1 -/�"' • <br /> „E H 1426 Rev. 1-74 1-7 IL 9M <br />