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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> v <br /> FOF�:OFFICE USE: 1601 E. Tlazelton Ave. , Stockton, Calif. f <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,9 71,5'}0 1 <br /> I <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) 1 <br /> Application is hereby nudes 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 Joaquini <br />_ County Ordinance No. 1862 and. thg Rules and Regulations of the San Joaquin Local Health District. <br /> vE , <br /> .TOB ADDRESS/LOCATION North side Idel.Io Road & 3/4 mile West Carlton Road , CENSUS TRACT 2't55l3O-19 <br /> Owner's Name Martin Vander Beek Phone <br /> Address 184 .2 E. Louise Five, Escalon, C Tif. 95320 City ' <br /> , l <br /> Contractor's Name Purviance Lrill.ers, Box 64, Linden, Calif. License # 21,01.07 Phone '931:-4468 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/_' RECONDITION /? DESTRUCTION /7 <br /> PUMP INSTALLATION /fie/ PUMP REPAIR/ { PUMP REPLACEMENT f7 <br /> Other /�/ <br /> DISTANCE TO NEAREST: SEPTIC ,TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LIFE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing jT, <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation 6iavel Pack-. '��Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal` .". '� 'T �O-ther__ _ µ- Other Information <br /> Geophysical Surface Seal Installed.'BY ..__ <br /> PUMP INSTALLATION: Contractor Furviance Dri'1.]ers <br /> Type of Pump 5Q-HE Turbine H.P. i <br /> PUMP REPLACEMENT: /7 State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION 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 per 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 the-best-of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTINQ D FINAL INSPECTION. <br /> SIGNED Oft TITLE <br /> DRAW YLOT PLAN ON REVERSE SIDE <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BY DATE ' — �- <br /> ADDITIONAL COMMENTS: <br /> PHASE I WECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DAFE INSPECTION BY. DATE <br /> a si. 1.110' 9u <br />