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f SAN JOAQUIN LOCAL HEALTH DISTRICT - <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone:' (209) 466-6781. <br /> AP ICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7z-'-5; 95 <br /> gg5yL <br /> HIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued 6-11- 7,?- 1 <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 /> 'X t`6.( 5�.: r4 1;-0- 'wr L �1 v <:2C�7- �7® -D� 4 <br /> JOB ADDRESS/LOCATION . N/Side Mariposa Rd, 1.o Mie E/O Dodds Rd. Jct, CENSUS TRACT <br /> Owner's Name Ed Leipelt <br /> Phone ' 838-2839 <br /> Address 23141 E. Mariposa Road ' ' y <br /> Cit Esca on <br /> Contractor's Name Purviance Drillers ,/ License 4 240107 Phone 931-"68 <br /> TYPE OF WORK (Check) : NEW WELL / I DEEPEN/a/ RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP. REPAIR / / PUMP REPLACEMENT 1-7 <br /> Other <br /> w <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> (Unknown) <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE,OF WELL r CONSTRUCTION SPECIFICATIONS <br /> Industrial X Cable Tool Dia. of Well Excavation ' <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> — Irrigation(E#ating) Gravel Pack : Depth of Grout Seal f� <br /> Other Rotary . Type of Grout <br /> Other _ Other Information Deepen 10n Well <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /-7 State Work Done <br /> PUMP REPAIR: / / State Work Done <br />.AESTRUCTION 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 true to the 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 -� �'-�� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P SE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BX DATE 6`l-- 0 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP ION. <br /> E H 1426 4/72 1M <br />