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SAN JOAQUIN,LOCAL HEALTH DISTRICT <br /> 'EOF.:OI FTCE USE: V//1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. j,1 , <br /> ' THIS PERMIT. EXPIRES 1. YEAR FROM DATE ISSUED Date Issued ,�- <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District £r a permit..66 construct <br /> and/or install the work herein described. ' This application is wade in compliance with San Joaquin <br /> County Ordinance No. 1$62 and the Rules and Regulations of the San Joaquin Local Health `Zistrict. <br /> JOB ADDRESS/LOCATION 690' South Prasher Re! on East side'Mk a 7.' -t CENSUS TRACT 106-100 - Z� <br /> Owner's Name Joe Dondero �, Phone <br /> Address 16299't. y 26, T:inden, Calif. 95236 f Cit <br /> Contractors Name Purvianee Dri1..?ers Pox 64, Linden, Calif. License, #%,."2 .0j07 Phone <br /> TYPE_ OF WORK (Check) : NEW WELL / DEEPEN -/ / ! RECONDITION /_/ DESTRUCTION /_7 <br /> f PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /-7 <br /> Other / JJ <br /> DISTANCE TO NEAREST: SEPTIC TANK g T1 SEWER LINES PIT PRIVY 1 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USETYPE OF WELL r CONSTRUCTION SPECIFICATIONS <br /> Industrial x Cable Tool Dia. of Well .Excavation Bit <br /> X Domestic/private Drilled a„ Dia. of Well Casing 811 �� } <br /> Domestic/public Driven .;>(Gauge of Casing IO <br /> Irrigation Gravel Pack r� Depth of Grout Seal 50 O ` <br /> Other Rotary Type of Grout = neet Cement <br /> Other Other Information 10' Conductor_ piFe for i r€ <br /> PLW INSTALLATION: Contractor Purviance DkIl ers <br /> Type of Pump :ubmersib16 H.P. 3 i <br /> PUMP REPLACEMENT. <br /> / / State Work Done � <br />--,PU�T_REPAItate ,Work .Done <br /> ,DFgTRUCTION OF WELL: Well Diameter t 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 9 <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 /> C <br /> 'SIGNED X ` TITLE Partner <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY I <br /> PHASE I ` <br /> APPLICATION ACCEPTED BY . y + . <br /> �. .. DATE <br /> '"I}ADDITIONAL COMMENTS: <br /> P E , GROUT INSPECTION ; P ITT F AL INSPECTION <br /> INSPECTION BY DATE. 6►] INSPECTION BY DATE r� <br /> --CALL -FOR`A-.GROUT-INSPECTION-PRIOR TO GROUTING AND .FINAL-INSPECTION. . 4 <br /> EHI.42G ` <br /> 5/731M <br />