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I _ of SAN JOAQUIN LOCAL HEALTH DISTRICT <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'. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) lea-3,3,0 --tY <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 146. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 2/10 Mile North Hwy 4 at end of Ilan Ajjen Road CENSUS TRACT <br /> Owner's Name R & J Dondero Phone <br /> Address !6299 E. :Hwy 26, Linden, Calif. City <br /> Contractor's Name.Purviance Drillers P.O.Bux 64,Linden, Calif. License # 240107 Phone 9314468 <br /> 9523 <br /> TYPE OF WORK (Check):- NEW--WELL--j7- DEEPEN RECONDITION / 'DESTRUCTION /-7 <br /> PUMP INSTALLATION f_1 PUMP REPAIR/ / PUMP REPLACEMENT / <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 3/4 IvIilSEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD S4 Mi CESSPOOL,/SEEPAGE PIT OTHER 3 <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 ZiMt ng lo" <br /> Domestic/ptivate Drilled Dia, of Well Casing Inst. 1411 T,iner <br /> Domestic/public Driven Gauge of Casing 10 <br /> X Irrigation 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 /> PUNK' INSTALLATION: Contractor <br /> Type of Pump _ - -- H.P. <br /> PUMP REPLACEMENT: / / 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 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 GROUTIN D A FINAL INSPECTION. <br /> SIGNED ys TITLE <br /> 117 DRAW-PZ T PLAN ON REVERSE SIDE) <br /> FOR PARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY .(/ GfT DAT <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIONP / INSPECTION ,` <br /> INSPECTION BY DATE INSPECTION B DATE - <br /> E H 1426 Rev. 1-74 <br /> 3/76 2M <br />