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FO& OFFICE USE: i / SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> (/ 1601 E. Hazelton Ave, , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued? <br /> Application is hereby made t (Complete <br /> o the San J aTriplicate) <br /> uinLocalHealthDistrict for a permit <br /> and/or install the work herein described. This application is made in compliancetwithnSan uJoaquin! <br /> :County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District., <br /> JOB ADDRESS/LOCATION 1,700' S, Hwy 26 & 1 mile E, 1auk Tone Road <br /> CENSUS TRACT <br /> Owner's Name crank Giannecchini <br /> Phone <br /> Address 15400 E. Hwy 26, Linden, Calif. <br /> City <br /> Contractor's Name Purviance Drillers, box 64, Linden, Calif. License # 240107 Phone `131.-41,.68 <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN Z7 RECONDITION /X_7DESTRUCTION /7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR/-7—PUMP REPLACEMENT <br /> Other L/ _ <br /> DISTANCE TO NEAREST: SEPTIC TANK 95' SEWER LINES PIT. PRIVY �� <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE�PiT_`7 OTHER_, , _ <br /> --PROPERTY-LINE-- PRIVATE DOMESTIC WELL'_ PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL .- CONSTRUCTION SPECIFICATIONS <br /> Industrial x Cable Tool Dia, of Well Excavation Existing 8" Tell <br /> X Domestic/private Drilled ' Dia. of Well Casing6-K <br /> Domestic/public Driven x 10 La- ccl umn <br /> Irrigation Gauge of Casing <br /> Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of'Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed Bv• <br /> PUMP INSTALLATION:t^'Contract r <br /> Type-of-Pump / H.P. I_ <br /> 'UMPRE— P_ LA_ CEMENT: � Lx/tate Work Done', Re-install 3 HP Turbine W <br /> )UMP .REPAIR: /% State Work Done= <br /> DESTRUCTION OF WELL: Well Diameter �. <br /> Approximate Depth <br /> Describe Material and Procedure <br /> 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 /> Lfter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> FELL 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 GROUT G A FINAL INSPECTION. <br /> IGNED TITLE <br /> PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> RASE I ���/ <br /> PPLICATION ACCEPTED BY DATE ' <br /> DDITIONAL COMMENTS: <br /> PHASE II G N E ION P AL INSPECTION <br /> NSPECTION BY DATE INSPECTION <br /> DATE <br /> E H 1426 Rev. 1-74 <br />