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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR!OFFICE,USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <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 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 350' Nest Buell Road and 3/10 Mile South Acampo RoadCENSUS TRACT <br /> Owner's Name Joan Graffigna Phone <br /> IAddress P. 0. Box 388 , I:odi, Calif. 95240' City <br /> Contractor's Name Furviance Drillers, P.O.Box 64 Linden Cal LfLicense # 240107 Phone 931-4468 <br /> - . <br /> 9S2 <br /> _ _ <br /> TYPE OF WORK (Check): NEW WELL _DEEPEN 17__RSCONDTION�/^:DESTRUCTION--/� � <br /> �Y__. .... �__-_—PTM-INSTALLATION)i7—PUMP'--REPAIR/� PU'-REPLAC NT 17 <br /> Other 1-7 — <br /> DISTANCE <br /> -7—DISTANCE TO NEAREST: SEPTIC TANK 200' SEWER LINES PIT PRIVY O <br /> SEWAGE DISPOSAL FIELD 200' CESSPOOL/SEEPAGE PIT _OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL 1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial x Cable Tool Dia. of Well'Excavation 1411 --- <br /> Domestic/private Drilled Dia. of Well Casing 1.4' fi <br /> Domestic/public Driven Gauge of Casing 1.0 <br /> X Ixrigation Gravel Pack Depth of Grout Seal , <br /> Cathodic Protection Ro�'ary Type of Grout' <br /> Disposal Other Other In€ormation <br /> Geophysics].. Surface_Seal Installed Bv: <br /> PUMP INSTALLATION: Contractor, Parviance Drillers <br /> - — i Type of Pump Ttx bine H.P. <br /> PUMP REPLACEMENT:. - / / State Work Done <br /> ' Z_7 State Wolk Done 7 <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 FIFT'EEN 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 FORA GROUT INSPECTION <br /> PRIOR TO GROUTING ANMMA FINAL INSPECTION. <br /> SIGNED t / r c.I-_', TITLE Fart lie r <br /> (DRAW PLOT.PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY '. DATE t �� <br /> ADDITIONAL COMMENTS: t `, ry:a.� <br /> PHASE If GROUT,,INSPECTION .., ,w PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE ' INSPECTION' BY DATE <br />,t E H 3.426 Rev. 1-74" 1-74 2M K <br />