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_ _ p <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> For_:OFF� .1� Cis USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (249) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z_3- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Z2-_Z,4'-,75 <br /> !"2'2 �f �c_" y4 �J • ' I (Complete In Triplicate) 00 5-- 2-"-0,3 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the wont 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 lieal.th District. <br /> .TOB ADDRESS/LOCATION 1 Nile (North Frazier & 1-3/4 Mile :East Tully CENSUS TRACT <br /> Owner's Name Graffigna_Br os. --- Phone <br /> Address 5221 E. Aeampo Road, Acampo, Calif., - City <br /> t <br /> Contractor's Name Purviance Drillers, Box 64, Linden, Calif. License # 240107 Phone 931-4468 <br /> TYPE OF WORK (Check): NEW WELL/x/ DEEPEN/_I RECONDITION / / DESTRUCTION _� <br /> AL <br /> PUMP INSTLATION REPAIR /—/—PUMP REPLACEMENT /-7 <br /> Other =/ / <br /> o � <br /> )]ISTANCE TO NEAREST: SEPTIC 'TANK miles SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> • Industrial x Cable Tool Dia. of Well Excavation 16n w',. <br /> - estic/ rate �-.z _ `Domp � <br /> lbn P1atDrivenAomestic/publiGauge of Casinge � <br /> X .:Irrigation Gravel Pack Depth of Grout Seal. <br /> 'Other Rotary Type of Grout <br /> Other er Infrbryjation , t <br /> 4, i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P <br /> PUI}li ,REPLACEMENT: / / State Work Done == <br /> r � *� ^�S ate Work Done r n <br /> PUMP--'tEPAIR: '" '� _� » 177/ <br /> ,DFRTRUCTION OF WELL: Well`Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i 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 /> 14ELL DRILLERS REPORT of the well and notify -them before putting the well in use. The above <br /> information is true the best of my knowledge and belief. <br /> SIGNED` TITLE Partner <br /> (DRAW PLOT XLAN ON REVERSE SIDE) <br /> FOR PARTMENT USE ONLY <br /> t - <br /> i PHASE I y DATE /0 4- -2 <br /> APPLICATION ACCEPTED B <br />' ADDITIONAL COMMENTS: <br /> PHASE .11 GROUT INSPECTION PHASE III/FINAL INSPECTION '1 <br /> INSPECTION BY DATE INSPECTION BY DATE - <br /> y . . .,-CALL-FOR A =GROUT-INSPECTION-PRIOR-TO GROUTING AND FINAL INSPECTION. <br /> ILITT „-IM . . 5/731M - <br />