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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 /> t <br /> HIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <br /> -J (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 3851 N. Vignolo CENSUS TRACT ; <br /> Owner's Name . Tom Prato * ` y Phone 931-4130 <br /> nolo <br /> Address 3851 N. Vi g City Stockton Calif. 95205 <br /> PO 1-Kalcense <br /> Contractor's Name Purvianee Drillers #240107 Phone 931- 68 <br /> TYPE OF WORK (Check) : NEW WELL AE/ DEEPEN '/—7 EC NDITI N\ DESTRUCTION /d- <br /> PUMP INSTALLATION / PUMP PAIR '/ / UMP REPLACEMENT /7 <br /> Other <br /> I <br /> DISTANCE TO NEAREST: SEPTIC TANK 551 SEWER LINES PIT P <br /> SEWAGE DISPOSAL FIELD CESSPO PAG P OTHER <br /> INTENDED USE TYPE OF WELL CO TION SPECIFICATIONS { <br /> Industrial x Cable Tool Dia. of Well ' cavation 8" — �a d <br /> X Domestic/private Drilled Dia. of ll C sing gn <br /> Domestic/public Driven Gauge of C ing 12 <br /> Irrigation Gravel Pack Depth of Gr eal _ 0 _ <br /> Other Rotary Type of Grout Neet Deme t <br /> _~' - Other Other Inf .mat on 1 n 72 ga C o Fiduct o}1 <br /> - I <br /> PUMP INSTALLATION: Contractor - Purviance -Drillers <br /> Type of Pump Existing Custoiher H.P. 1 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: /�/ State Work Done <br />.pESTRUCTION OF WELL: Well Diameter 6" Approximate Depth 100 <br /> i <br /> Describe Material and Procedure Neet 0AInok 01.. 1001' , <br /> I hereby agree to comply with all laws and regulations of the S quin Local Health District <br /> k <br /> and the State of California pertaining to or regulat 1 con ruction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will fu s h San oaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them b , r "utta the well 'i.n use. The above <br /> informat'on is true to the best of my knowledge beli <br /> r - w <br /> SIGNE <br /> (DTAW P <br /> EM PLAN ON REVERSE S <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DAT <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INS TION <br /> INSPECTION BY , ATE ' INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR'TO GROUTING AND FINAL INSPECTIO <br /> E H-1426 4/72 1M <br />