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SAN JOAQUIN LOCAL HEALTH DIST.RIC''T <br /> f,:E671�eOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781/� <br /> APPLICATION FOR WELL CONSTRUCTION OR PUTP PERMIT Permit No. l� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> fpolication is hereby made to the San Joaquin Local Health Districtfor a permit to construct <br /> nd/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No./ 1862 and',ph Rules and Regulations of the San Joaquin Local Health District. <br /> [jOB ADDRESS/LOCATION In mile South of Co 3peropolis Vio `d of CENSUS TRACT <br /> Escs cin Ba o a ia. <br /> er's Name R. & J. S nguinetti Phone <br /> Address City Linden <br /> 4468 <br /> ;ontractor's Name PULViance drillers License ## 2401C7 Phone 931-3-0k <br /> 1 <br /> 'FY <br /> PE OF WORK (Check): NEW WELL /g7 DEEPEN '/—/ RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION /X/ PUMP REPAIR /—/--PUMP REPLACEMENT /7 <br /> Other / / <br /> ASTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> ` SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> _ PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> i Industrial X Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing3?02K-1611 <br /> Domestic/public Driven Gauge of Casing 216 plate } <br /> _ Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information M1 \1 <br /> Geophysical Surface Seal Installed By-:- <br /> PUMP <br /> yePUMP INSTALLATION: Contractor Purviance drillers <br /> Type of Pump turbgLn H.P. <br /> PUMP REPLACEMENT: /T// State Work Done <br /> F'UMP `.REPAIR: / / State Work Done <br /> p'OES:TRUCTION 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 /> Fnd the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> fter completion of my work on a new well, I will furnish the San Joaquin Local. Health District <br /> WELL DRILLERS REPORT of the well and notify them before putting..the- well in use.. The above <br /> nformation is true to the best-of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> RIOR TO GROUTTNGAND A FINAL INSPECTION. <br /> -SIGNED 1 TITLE rtne <br /> r- (DRAW PLOT PLAN ON REVERSE SIDE <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> DDITIONAL COMMENTS: —- - - - - <br /> ' PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 7-2-4 <br /> . . 7 t� <br /> E H 1426 • Rev. 1-74 s. <br /> 1-7G 9Ad <br />