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F <br /> SAN OAQUIN LOCAL HEALTH DISTRICT <br /> For. OFFICE USE: 1' 01 E. aze1ton Ave. , Stockton, Calif. <br /> lephone: (209) 466-6781 <br /> f" P ATI FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7#-,1.1-14,1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br />,.r (Complete In Triplicate) <br /> Application is hereby tide 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. 1:862 and the Rules and Regulations of the San Joaquin Local. Real.th District. <br /> JOB ADDRESS/LOCATION 3/4 Mi. East Fine Rd. & Mi. South Calaveras RiveCENSUS TRACT <br /> Owner's Name Ray Young Phone <br /> Address 923 Santa Rita Road, Pleasanton, Calif, City <br /> Contractor's Name Purvianae Drillers P.O.Box 64, Linden License # ?,x,0-10? Phone 931,44.E <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/_/ RECONDITION /a/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / J PUMP REPLACEMENT / <br /> Other <br /> DISTANCE-TO- NEAREST: SEPTIC TANK j Mi. 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 Existing 14" <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> z Irrigatio'n' Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information Inst. 12" Liner <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /x/ State Work Done-, Inst 40 HP Pump {Turbine} <br /> PUMP Ut AIR:' / / State Work Done <br /> ,DFgTRUCTION -OF WELL: Well Diameter Approximate Depth c <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 neer well, I will furnish the San Joaquin Local Health District a <br /> WELL DRIL j.' ' APO - the welt, and notify them before putting the well in use. The above <br /> inforur tion is iue o t e be t of my knowledge and belief. <br /> SIGNED -��� - TITLE Partner <br /> < — (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I c� <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMIT:NTS: - - - <br /> PHASE II GROUT INSPECTION PHASE III/FINAL-INSPECTION <br /> INSPECTION BY DATE INSPECTION BYE----- DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> e /7'1 <br />