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SAN JOAQUIN LOCAL HEALTH DISTRICT / <br /> FOR1OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.77 173 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedDFC 22 1977 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District: for a permit to construct <br /> anti/or install the work herein described. This application is wade in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquir Local Health District. <br /> .TOB ADDRESS/LOCATIOjf0 I South of Sheldon Rd./9201 West � GilmortE��TRACT d 23 -��-o`r <br /> Owner's Name Dan Compton Phone <br /> Address P. 0. Box 606 City Woodbridge, Ca <br /> Contractor's Name Purviance Drillers License # 21•0107Phone 931-�468 <br /> TYPE OF WORK (Check): NEW WELL /��".. DEEPEN ' 77 RECONDITION /_� DESTRUCTION /_7 <br /> PUMP INSTALLATION /X/ .PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial XXXXCable Tool Dia. of Well-.Excavationy,, 14+11 <br /> Domestic/private Drilled Dia. of Well Casing 1` 11 X 109a <br /> Domestic/public Driven Gauge of-Casing ' 10 <br /> i irigat3oin 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 PUrVianm Drill"er:S <br /> Type of Pump Turban •- H.P. '1 j;,nk_ <br /> PUMP REPLACEMENT: j_/ State Work Done , <br /> PUMP-REPAIR: /? State Work Done <br /> E&TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> Q <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. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTINGD FINAL INSPECTION. <br /> SIGNED r , TITLE Partner <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I9 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II G OUT INSPECTION P II INAL INSPECTION -� <br /> INSPECTION BY DATE INSPECTION .BY. SATE <br /> E H 14.26 Rev. 1-74 1-74 2M <br />