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F0K OFFICE USE: SAN JOAQUIN LOCAL HEALTH DISTRICT SCANNED <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. \\ <br /> �2 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED !/ <br /> Date Issued <br /> ( <br /> Application is hereby made to the San Joaquin e <br /> Lo al HealthDistrictfor 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 350' Weruck Road and 3110 Mile South Acam o`Road 24e) Z� <br /> P CENSUS TRACT <br /> Owner's Name John Graffigna <br /> Phone <br /> Address P. 0, Pox 388 , Todi, Calif, 95240 <br /> City <br /> Contractor's Name Purvia ,ce Drillers P,G.Box 64 Tinden Cno ' fLicense 11 21,0107 Phone 931-4468 <br /> 952" <br /> TYPE OF WORK (Check) : NEW WELL A7 DEEPEN Q RECONDITION /-7DESTRUCTION /-7 <br /> AL <br /> PUMP INSTLATION Ac / PUMP REPAIR /% PUMP REPLACEMENT /-7 <br /> Other /% — <br /> DISTANCE TO NEAREST: SEPTIC TANK 200' SEWER LINES PIT PRIVY N <br /> SEWAGE DISPOSAL FIELD 200' CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL _ PUBLIC DOMESTIC WELL <br /> USE <br /> INTENDED TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial x Cable Tool Dia, of Well Excavation 1,; <br /> Domestic/private Drilled Dia, of Well Casing l4" <br /> Domestic/public Driven Gauge of Casing 10 <br /> x Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Purviance Drillers <br /> Type of Pump Turbine H.P. 10 <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP '.REPAIR: State Work Done <br /> ,)ESTRUCTION 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 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 A FINAL INSPECTION. <br /> SIGNED ' TITLE Partner <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY �� 1 L� DATE L Z <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PRASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - Z" <br /> E H 1426 Rev. 1-74 / <br /> 1-74 2M <br />