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SAN JOAQUIN LOCAL HEALTH DISTRICT11r. <br /> `t FOE OFFICE USE: z 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466=6781 , <br /> APPLICATION FORTWELL CONSTRUCTION OR PUMP PERMIPermit No. <br /> if THIS PERMIT EXPIRES YEAR FROM DATE .ISSUED Date Issued.a__16 <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 /> lations of the San Joaquin. Local Health District. <br /> County Ordinance No. 1862 and the Rules and Regu <br /> t JOB ADDRESS/LOCATION j_'im:,le north Of Comstock R+dA— 001 E TRACT <br /> Owner's Name Del Gotelli Phone <br /> .t <br /> tcity -Stockton <br /> Address 91+21. N._Ashle_ -� <br /> f <br /> Contractor's Name Purviane e Drillers License # 211-0107 Phone "931-1+1{68 <br /> .i <br /> TYPE OF WORK (Check) : NEW WELL /� DEEPEN / / RECONDITION / / DESTRUCTION /�_,, <br /> 11 Pump INSTLATION "/ I PUMP REPAIR / / PUMP REPLACEMENT /� "� <br /> AL <br /> 1` Other / rebowling_to c age ' hor eppwer" <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER" LINES �' " .PIT PRIVY VA <br /> SEWAGE DISPOSAL FIELD `:CES5POOL/SEEPAGE PIT OTlER4 <br /> PROPERTY LINE — PRIVATE DOMESTIC WELL '--, PUBLIC DOMESTIC WELL <br /> s INTENDED USE !? TYPE OF WELL : x CONSTRUCTION SPECIFICATIONS <br /> 'Industrial , Cable Tool Dia,40f Well Excavation,.'" <br /> Domestic/privatei; Drilled Dia. of Well Casing - <br /> ! � Q <br /> "'Domestic/public 11 �� Driven Gauge of Casing .� <br /> g Irrigation.. <br /> ' ° Gravel Pk Grout Seal <br /> .....,.;;, _ _ _ Pack Depthof <br /> it - - �R�tary -- .Type of Grout - — - -", <br /> Cathodic=-Protection <br /> " Disposal li Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: " Contractor Purviance Drillers <br /> Type of Pump turbine was 2 ` H rH.Pd 30HP - _ <br /> PUMP REPLACEMENT: X / State Work Done char ng bowls t0 30HP _ <br /> PUMP .REPAIR: u / / State Work Done <br /> i DESTRUCTION OF WELL: i 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 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 /> r information is t ue the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTIN D `' FINAL INSPECTION. <br /> SIGNED ; : TITLE <br /> DRAW. PLOT PLAN ON REVERSE SIDE) <br /> { FOR D11PARTMENT USE ONLY <br /> PHASE I �1 <br /> APPLICATION ACCEPTED BY �2DATE �v <br /> } ADDITIONAL COMMENTS: 11 <br /> PHASE IIIIGROUT INSPECTION PHASE II/FINAL INSPECTION <br /> INSPECTION BY p DATE INSPECTION BY / DATE <br /> 3/76 2M <br /> E H 1426 Rev. 1 .174 - - <br />