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. SAN JOAQUIN LOCAL HEALTH DISTRICT tIHr <br /> FOgiOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. j <br /> Telephone: (209) 466-67$1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.177 I63S , <br /> THIS PERMIT EXPIRES ] YEAR FROM DATE ISSUED Date Issued <br /> L L7 <br /> (Complete In Triplicate) <br /> Application is hereby made to the 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 Mules and Regulations of the San Joaquin Local Health District. <br /> (18380 E. Comstock) <br /> JOB ADDRESS/LOCATION 200',.South Comstock & Mile East Duncan Roads CENSUS TRACT <br /> Owner's Name Vaccarezza Eros. `t. Phone <br /> Address 18380 E. Comstock Road, Linden, Calif. 94236 City <br /> r <br /> Contractor's Name Purviance Drillers P.O.Box 64 Linden Calif License # 240107 Phone 932-41+68 { <br /> J 95236l 1 <br /> TYPE OF WORK (Check).- ..NEW WELL,/-T,,-;DEEPEN `./ ""RECONDITION /-x7- ' 'DES�TRUC-TION' f_7PUWP INSTALLATION %' / PUMP REPAIFR / / PUMP REPLACEMENT /ST <br /> Other <br /> DISTANCE TO NEAREST:- SEPTIC TANK x.00' SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 100' CESSPOOL/SEEPAGE P�T OTHER <br />{� =° PROPERTY LINE -- PRIVATE DOMESTIC WELL` PUBLIC DOMESTIC WELL <br /> 'INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> "-Industrial , 4 x Cable Tool Dia. of Well Excavation eepen ing 12" 'Well <br /> Domestic/private -iii Drilled Dia.- of Well Casing & Insto U near <br /> Domestic/public f Driven Gauge of Casing <br /> g Irrigation _ _ _Gravel_Pack-\ Depth_of_Grout-Seal <br /> Cathodic Protection i Rotary Type of Grout C� . <br /> Disposal 4 Other Other Information-,,s <br /> Geophysical ;s.. "� Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor u <br /> Type, of Pump H.P. <br /> PUMP REPLACEMENT: /g/ I State Work Done Replace 30 HP Pump <br /> PUMP 1EPAIR: /? State Work Done i E: <br /> PE&TRUCT,ION OFWELL: WelllDiameter 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!, on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT o he, well and notify them before putting-the- well in-use.. The above <br /> informs n is tru th best of my knowledge and belief. I WILL CALL FOR A -GROUT INSPECTION <br /> PRIOR GROU G AL'INSPECTION. <br /> SIGN TITLE Partner <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> r PRASE I <br /> APPLICATION ACCEPTED.BY, DATE <br /> ADDITIONAL COMMENTS: <br />' PHASE II GROUT INSPECTION PHASE 41IIFINAL INSPECTIPN <br /> INSPECTION BY DATE INSPECTIONBY DATE 'a.E H 1426 <br /> ---�. <br /> Yj, Rev. 1-74 _ 1-74 2M _ <br />