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�..•.."�,,,. ",_ (; S f"O"JOAQUTN LOCAL HEALTH DISTRICT <br /> FOE;OFFICE USE: 1601Hazelton Ave. , Stockton, Califf. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR. WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7A- <br /> AT <br /> pl <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUE ed <br /> Application is hereby made to the S (Complete In Triplicate) <br /> 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 Joaquii <br /> County- Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> ` JOB ADDRESS/LOCATION East side Clements Road, Forth side Dead-end Branca A <br /> t+ CENSUS TRACT <br /> Ro a <br /> .Owner's- Name. Darwin Tewis <br /> Phone <br /> Address 23X19 E. Brandt Road, T.odi, Gail . '95240 <br /> City <br /> Contractor's Name Purviance Dril.l.ers,Box 64.,T,inden,Calif.95236License # 210-1:07 Pil <br /> hone 931- 468 <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN -/_" RECONDITION /_7 DESTRUCTION <br /> PUMP INSTAAJ LATION _11 PUMP REPAIR '/� PUMP REPLACEMENT 1i.x <br /> Other / / i-"" <br /> ' DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES �� <br /> SEWAGE DISPOSAL FIELD PIT PRIVY <br /> CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -» PRIVATE DOMESTIC WELL" PUBLIC <br /> INDOMESTIC WELL <br /> NTEDED USE TYPE OF WELL <br /> IndustriaCONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation ,j <br /> Domestic/private Drilled Dia. of Well. Casing i d <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodid Protection. Rotary Type of Grout b1„ <br /> 4 Disposal Other11 <br /> ""'—` --- Other Information <br /> Geophysical <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: /x/ State Work Done Repair and _replace original <br /> . . .. -pump <br /> i _ <br />' PUMP REPAIR: / / State Work Done <br /> ]ESiTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate "Depth , �\ <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. Withix 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 the well and notify theca before putting the""well. in use— 'The above <br />' Lnforma on s tr he. est of..my..knowledge and belief. I WILL CALL "FOR A GROUT INSPECTION <br /> 'RIOR GR TI F AL INSPECTION. <br /> 3IGNE <br /> ji <br /> TITLE Partner <br /> (DRAW PLOT PLAN ON REVERSE SIDE) j <br /> 'RASE I R DEP TMENT USE ONLY ,y <br /> d'P A ION' ACCEP <br /> 1DDITIONAL COMMENTS: DATE ��- -17 <br /> PHASE lI GROUT INSPECTION , <br /> [NSPECTION BY PHASE",I FIN INSPECTION <br /> DATE INSPECTION BY" DATE' <br /> E H 1426 Rev. 1-74 <br />