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' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR+t'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 o y <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued , <br /> (Complete In Triplicate) <br /> Application is hereby made to the Safi 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 Regtklations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 1110 Wile East Bruella & 3 30ik*Ae rr Acampo CENSUS TRACT <br /> Owner's Name Bal_ph Graffi.gna __ _ ` Phone <br /> Address -2300 W. Tokay Street Lodi, Ca?if. ,95;24:0 City <br /> ' 0 Po7 64,Linden Ca, if`License # 240107 Phone 931.-4468 <br /> Contractor's Name Purviance Drillers F. , <br /> TYPE OF WORK ((%eck}: NEW WELL A-T DEEPEN -/7 RECONDITION / T DESTRUCTION /-7 <br /> AL <br /> PUMP INSTLATION REPAIR /-7-pump REPLACEMENT FT <br /> ` Other /-7 — — — <br /> DISTANCE TO NEAREST: SEPTIC TANK 100' SEWER LINES; � PIT PRIVY <br /> SEWAGE DISPCZAL FIELD- '16o"t CESSPOOL/SEEPAGE PIT OTHER r <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC'bOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of .Well'Excavation 10" , <br /> j a. Domestic/private Drilled Dia. of Well Casing '10" <br /> Domestic/public Driven Gauge of-Casing 10 <br /> ,•-Irrigation Gravel Pack Depth of-Grout Seal 55 - 1.4" Dia. A <br /> Cathodic Protection Rotary Type of Grout Neet Cement <br /> Disposal Other Other Information <br /> Geophysical 'Surface..Seal Installed B : <br /> PUMP INSTALLATION: Contractor- <br /> Type <br /> ontractor Type of Pump ! A.P.= <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP'i.REPAIR: <br /> ,?ESTRUCTION OF WELL: Well Diametler Approximate Depth <br /> Describe M+ terial 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 /> information is true to the-best-of- my knowledge and belief. I WILL CALL FOR-A-GROUT INSPECTION <br /> PRIOR TO GROUTING ANA A Y4NAL INSPECTION, <br /> SIGNED TITLE Partner <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> VV FOR DEPARTMENT USE ONLY <br /> F PHASE I ' <br /> APPLICATION ACCEPTED__,BY - - - DATE- Z -- <br /> ADDITIONAL COMMENTS:— _ _ . <br /> PHASE II GROUT INSPECTION PHASE `III FINAL INSPECTION <br /> k3 INSPECTION BY DATE INSPECTION BY DATE7 <br /> F <br /> i E H 1426 Rev, I-74 i-74 2M - <br />