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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. y3'79(cJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED - Date Issued , 73 <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 17200 E. Hwy 26 CENSUS TRACT _ <br /> Owner's Name E. L. Snyder Phone 88743679 -- <br /> Address 17200 E. Hwy 26, Linden, Calif.9"5236 <br /> City <br /> Contractor's Name Puivi,ance Drillers Box 64 Linden �Calif. License 4� 240-107 Phone 931-"68. <br /> TYPE OF WORK (Check).:, NEW WELL /x% DEEPEN / / RECONDITION /� DESTRUCTION /- <br /> �: . _ _ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_ ` <br /> `^- `. :,.Others <br /> DISTANCE TO NEAREST: SEPTIC TANK ©_ .. ._ SEWER. LINES P, T PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION�SPEC�11211 <br /> ONS <br /> Industrial g Cable Tool -- ._ Dia, of Well Excavation• Domestic/private Drilled Dia. of Well Casing <br /> _ Domestic/public Driven Gauge of Casing 1-0 <br /> x Irrigation � � <br /> $ Gravel Pack - - Depth of Grout Seal 50 <br /> Other Rotary Type of Grout ea --Cement <br /> Other .Other Information <br /> PUMP INSTALLATION: -;Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: s / / 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 he best of my knowledge and belief. <br /> SIGNED r <br /> TITLE Partner <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> --� FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY , DATE <br /> ADDITIONAL COMMENTS: - — <br /> PHASE II UT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY _ DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7172 1M <br />