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SAN JOAQUIN LOCAL HEALTH- DISTRICT T <br /> FOE OFFICE-USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,j -q( <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 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. 1$62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 3737 N. Duncan Rd. CENSUS TRACT <br /> Owner's Name- Bill J. Purviance Phone <br /> Address N. Duncan Rd. City Linden <br /> Contractor's Name Purviance Drillers License # 21+0107 Phone 9-11-L,,J+68 <br /> TYPE OF WORK (Check) : NEW WELL/ J DEEPEN RECONDITION /R/ DESTRUCTION /-7 T <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT A-7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY 'J <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER W <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL 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 Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Informationi g lilineraw-tis <br /> Geophysical Surface Seal Installed By: " Wp <br /> and rill between 10" & 8" casing with <br /> PUMP INSTALLATION: Contractor ineet cement <br /> Type of Pump g,P. <br /> PUMP REPLACEMENT: . / State Work Done re stall <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 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 GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> partener' <br /> 77 D W. PI} T 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 PHAS III , NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 3 Z 3 7, <br /> E H 1426 Rev. 1-74 <br /> 3/76 2M <br />