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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone:. (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ��?-_ lr/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued J � <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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 0 E,_Ea 26 CENSUS TRACT ' <br /> Owner's Name Karl Grupe Phone <br /> Address _1 4 E. Hwy 26, Linden, Ca".if. City <br /> Contractor's Name Purviance Drillers2 P.O.Box 64,. Linden License ,1i .2Y6107 Phone I- 4Jf <br /> 95236 <br /> TYPE OF WORK (Check) : NEW WELL /:i/ DEEPEN /_/ RECO16ITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION J / PUMP REPAIR '/—/ PUMP REPLACEMENT J? <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPEC_IFI-CATIONS <br /> Industrial Cable Tool Dia. of Well Excavation/ l4" <br /> Domestic/private Drilled Dia, of Well Casing ;14" o <br /> Domestic/public Driven Gauge of Casing w' _10 _ -C. <br /> X Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information- <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump fF H.P. <br /> j PUMP REPLACEMENT: / / State Work Done • <br /> PUMP REPAIR: / / State Work Done,I. <br /> ,PESTRUCTION 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 tru the best of Amy knowledge and belief. <br /> SIGNED TITLE <br /> / (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR ARTMF USE ONLY <br /> PHASE I _ <br /> APPLICATION ACCEPTED BY / .r/�, DATE //J <br /> -112 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIIJ NAL INSPECT ON <br /> INSPECTION BY DATE INSPECTION BY �- 6, , DATE ' <br /> CALL FOR A GROUT. INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br /> , <br />