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L" <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO—S OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2�Lo <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1i-r-76 <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 Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION North side Baker Road, 200 Yds. Dead-end Archerdalq CENSUS TRACT 1 <br /> Owner's Name Geo. Ferrari & Son Phone <br /> Address 5960 N. A rcherdal a Road, T.inden, Ca'►if. 95236 City <br /> Contractor's Name Purviance Dril l ers,Box 64 jinden,'Cal if.95236License # 240-107 Phone 931-4.468 <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN 47 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION /_/ PUMP REPAIR A-7 PUMP REPLACEMENT /z? <br /> Other /% <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL* PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �V1 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> x Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic ProtectionRotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /x/ State Work Done Repair and replace original pump <br /> PUMP,REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: 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 we11 '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 /> informatio s true to the-best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR GRO I GFi INSPECTION. <br /> SIGNED <br /> TITLE Partner <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> OR DE TMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPM DATE . ` <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT I ECTION PHASE IIIIFINAL INSPECTION <br /> INSPECTION BY 'FATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br />