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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 No. _]� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 47Lq-7 v <br /> (Complete In Triplicate) <br /> Application is reby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install t 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 /> JOB ADDRESSJLOCATION 20241 E. Watnttt Drive CENSUS TRACT <br /> Owner's Name Mrs. F. L. Meier Phone 931-"68 <br /> Address % Gary Giannecchini F. 0. Box 2 31 p Linden, CalfPl, City <br /> Contractor's Name Purviance Drillers, P.O.Box 61+, Linden License # 240-107 phone 931-4468 <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/—/ RECONDITION /'7 DESTRUCTION /`7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /X <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation — <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> 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: /S/ State Work Done Pull 1051 Jack Pump, install HP Submersible Pump <br /> _ and install well seas. <br /> PUMP 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 /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work o ew well, I will furnish the San Joaquin Local Health District a <br /> WELL DRIL PO o ell an notify them before putting the well in use. The above <br /> inform on is t e to e b st of knowledge and belief. <br /> SIGNED * yU a TITLE pn®p <br /> {DRAW FLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I \1 <br /> APPLICATION ACCEPTED BYDATE 1 7-1_ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY <br /> CALL FOR A GROUT INSPECTION PRIOR TO -GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />