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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORfOFFICE US : 1601 E. Hazelton Ave. , Stockton, Califs <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. d'3 <br /> e <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 Rules and Regulations of the San Joa uin=Local Stealth District. <br /> jDu�n�ca' '- <br /> JOB ADDRESS/LOCATION .6 gile <br /> , pperopot �� oa .5 �iZeest ACT <br /> Owner's Name John Cava naro Phone <br /> Address P. 0. Box 20l Va?.1-e S rin s Cad if. 95252 Cit <br /> Contractor's NamePurviance Dril-Tars P.O.Box 64 Linden Calif. License # 240107 Phone 931-4468 vi <br /> 95236 <br /> i <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN -/-x7 RECONDITION /_7 DESTRUCTION /f Q` ' <br /> -INS%ALAT_..IO.N-,./ � UMP REPAIR -�I ,I- PUMP REPLACEMNT �PUMP # <br /> Other / <br /> - <br /> - <br /> a <br /> DISTANCE TO NEAREST: SEPTIC TANK 1 Mile SEWER LINES PIT PRIVY ' <br /> SEWAGE DISPOSAL FIELD I MileCESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL-1-Mi-PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL <br /> COI3STRUCTION SPECIFICATIONS o <br /> Industrial x Cable Tool Dia. of Well Excavation 11;3dsting 1411 € <br /> Domestic/private Drilled Dia. of Well Casing Inst. I-0 ftsiM Colu= L �6 e' <br /> Domestic/public f .. Driven Gauge of Casing 107 <br /> X Irrigations • Gravel Pack Depth of Grout Seal <br /> _ Cathodic Protection Rotary Type of Grout fi <br /> Disposal '\ :, %. Other �� Other Information h <br /> Geophysical Surface Seal Installed By. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP. PLACEMENT/x/ State_Work_Dane .._..Insta't� customer HP Turbine <br /> _ . - - � ._ <br /> I <br /> PUMP ,.REPAIR: /7 State Work Done <br /> E&TRUCTION OF WELL: Well Diameter Approximate Depth <br /> ----- <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 l <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 /> information is true to the-best-of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION j <br /> PRIOR TO GROUTING AND FINAL INSPECTION, t- <br /> SIGNED t f <br /> TITLE Partner <br /> -1(DRAW PLOT PLAN[ON REVERSE SIDE <br /> PHASE I � DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED By <br /> DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION `� �s' w j PHASE III FINALINSPECTIQINSPECTION BY DATE ,_ <br />�� E H 1426 Rev. 1-74 t 1-7L 9M <br />