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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 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> pplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> Lnd/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 /> OB ADDRESS/LOCATION ]4/04 E Hwy 26 CENSUS TRACT <br /> owner's Name Karl Grupe <br /> Phone <br /> 4tddress 71,1,.04 E. Hwy 26, T inden, Calif. City <br /> ontractor's Name Purviance Drillers P.O.Box 64, Linden License # .24d d Phone <br /> ` 95236 <br /> YPE OF WORK (Check) : NEW WELL /Sj DEEPEN '/-7 RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTLATION REPAIR / / PUMP REPLACEMENT /� <br /> AL <br /> ` Other /-7 <br /> ISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISWSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial x Cable Tool Dia, of Well Excavation 144 <br /> Domestic/private Drilled Dia. of Well Casing 14° o <br /> Domestic/public Driven Gauge of Casing 10 'Z <br /> z 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 H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> UMP 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 /> nd 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 a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> ;nformation is tru the best of my knowledge and belief. <br /> 63IGNED / ! r.c c_<a�� c TITLE �lw <br /> ✓ (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR <br /> TMENT USE <br /> ARS—ONLY <br /> •PHASE I fA <br /> APPLICATION ACCEPTED BY ,, „�,,, � Ste, DATE <br /> DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/I NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE7r�->� <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1N <br />