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l ob td - SAN JOAQUIN LOCAL HEALTH.DISTRICT <br /> FF—OF-"OFFICE USE: <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) .466-6781 18. 9 ! <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Iv 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ;11 (Complete In Triplicate) <br /> Application is hereby made tw'ithe 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 /> South side Milton Road & 1ile West Deitrich Rd. CENSUS TRACT <br /> JOB ADDRESS/LOCATION _ _ _ <br /> Owners Name Yoim'in Gerberj Phone i <br /> A <br /> Address 19958 E. Milton Roada _n_l�en, Calif.N 95236 City <br /> Contractor's Name Purviance Drillers P.O.Box 64 T,inden Cal if. License # 21,.OZ07 Phone 93?;-L,468 I <br /> 9 52 <br /> TYPE OF WORK (Check) : NEW DEEPEN / / RECONDITION � ESYTRUCTION;/ Y <br /> - - _-r�=r-- --a'PUMP-YNSTALILATION /7/" 7PUI�`REPAIR'I=�'�PUMP- PLACEMENT':`/8T <br /> F Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 100' SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 1001 CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE ..- PRIVATE DOMESTIC WELL -5a! PUBLIC DOMESTIC WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE' TYPE OF WELL " <br /> Industrial l.x Cable Toolilled Dia. of Well Casing <br /> Dia. of Well Excavation 12 } <br /> DrZ2 <br /> Domestic/private � Gauge of Casing 10 <br /> Domestic public 1 Driven F g <br /> -- -T�"" Gravel Pack Depth of Grout Seal <br /> ra Irrigation �r Type of Grout <br /> Cathodic Protection ;I - ,Rotary; <br /> Other Other Information <br /> Disposal --_—_ - Surface Seal Installed By.: <br /> Geophysical t� <br /> PUMP INSTALLATION: Contractor _ _ T H.P. <br /> Type :of Pump <br /> PUMP REPLACEMENT: <br /> :tW�Wo` W--Done I tag1'Customer,6.30-H1'-Tvxtrine <br /> PUMP REPAIR: / / State Work Done <br /> -Approximate <br /> DESTRUCTION- OFFWEL-t% Well Diameter <br /> Describe Maternal and Procedure <br /> # I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> tion. Within FIFTEEN RAYS <br /> and the State of California pertaining to or regulating well construc <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 /> f information is true to a best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROU IMG 4NpA ANAL INSPECTION. TITLE "ATE <br /> SIGNED ! D W P T PLAN ON RE RSE SIDFOR DEPARTMENT USE ONLY <br /> PHASE I ° �J <br /> APPLICATION ACCEPTED BY �yv <br /> s ADDITIONAL COMMENTS: P SE I AL INSPECTION <br /> �. PHASE II GROUTIINSPECTION` J NSPETION ,SATE <br /> INSPECTION BY .!DATE <br /> 3/76 29 <br /> E H 1426 ___ Rev. 1--74 _ <br />