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i� <br /> y "- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1641 E. Hazelton Ave. , Stockton, Calif. <br /> - ;j Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7T <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued F <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 Saiz Joaquin <br /> County�Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> F-j � _ <br /> JOB- ADDRESS/LOCATION 3G0' South of Ni1to ' o 75' East iorman S1_uu CENSUS TRACT <br /> E n CAT-- ;aP%-C9w. 'Kd <br /> Owner!s Name SariIot Dike <br /> Phone <br /> Address ...sack Tone Roaa., Stockton, Calif. 95205 City <br /> Contractor's Name Purvianc.e Dril l ers,P.0. Box 64,T,inden,Calif.License # ?2,•0107 Phone 931-41+68 <br /> v5z36 i <br />__TYPE OF WORK�(Check)_� I�EW WELL. / /._ DEEPEN / I RECONDITION DESTRUCTION_/� p <br /> PUMP INSTALLATION / / PUMP REPAIR / PiiMP 'REPLACEMENT` �/� + <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 'S <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL -. ` ' <br /> INTENDED USE 0 . TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable'`ToolA Dia, of Well Excavation _^ <br /> --_ -- _- - -- __ <br /> Domestic/private - Drilled - _ — Dia.. of Well. Casing. _ <br /> Domestic_/_public ` Driven Gauge of Casing <br /> ? Gravel Pack Dep <br /> of Grout Seal. <br /> x <br /> Irrigation", ii _ <br /> i Cathodic Protection Rotary Type of Grout {_ <br /> Disposal ; Other Other Information ' - <br /> Geophysical Surface Seal Installed B : <br /> PUMP INSTALLATION: Contractor <br /> li Type of Pump H.P. <br /> PUMP REPLACEMENT: /-7 State Work Done <br /> `PUMP�,REPALR-:- 1?�/"rState Work Done,��uL1 existi�zg 20 iTP I?wnp 3ristal.l` wi h nervi' or y <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> a , <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-we11 '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. I WILL CALL FOR A GRO INSPECTION <br /> PRIOR TO GROUTING A' FINAL INSPECTION. <br /> SIGNED °� TITLE Partner <br /> DRAW Ph T"PLAN 'ON RE FRSE SIDE E <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> p <br /> f APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL. COMMENTS: - <br /> PHASE II GROUT INSPECTION P E T FINAL INSPECTION <br /> INSPECTION BY DATE INSP�TION B DAT - <br /> 3,76 <br /> E H 1426 Rev. 1-7.4 <br />