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C'+^ ✓ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF.*:OFFICE USE; 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 73-5,p .ed <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /4L_j4-73 <br /> (Complete In Triplicate) pys-22o-03 <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 i MilelNorth Frazier & 1-3/4 Mile East Tully CENSUS TRACT <br /> Owner's Name Graffigna Bros. Phone ; <br /> Address 5221E Acampo Road Aeampo, Calif.. City <br /> Contractor's Name Purviance Drillers Box 64, Linden, Calif. License R 240107' Phone 931-4468 <br /> f <br /> TYPE OF WORK (Check): NEW WELL /W DEEPEN '/ MP RECONDITION /-T DESTRUCTION /-T <br /> PUMP INSTALLATION PUREPAIR /-T PUMP REPLACEMENT C7 N <br /> Other :/ / <br /> DISTANCE TO NEAREST: SEPTIC `TANK miles SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER fh <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial a Cable Tool Dia. of Well Excavation It., <br /> ; -'bomestic%Private— _-+Dri1�.e-dy,.•- „ =-�— -- --4 <br /> Domestic%public Driven Gauge of Casing 1 P-'Ate <br /> -i—,,:Irrigation Gravel Pack Depth of Grout Seal <br /> 'Other Rotary Type of Grout <br /> Other Other In tion <br /> { <br /> PUMP INSTALLATION: Contractor - <br /> f <br /> Type of Pump H.� .'. <br /> PUMP REPLACEMENT: / / State Work Done <br /> - PUMP-REPAIR: �1_ -� - 7S{ to Wbrk^bone <br /> ,DFqTRUApproximate CTION OF WELL: Well' Diameter PP 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 the best of my knowledge and belief. <br /> � • - TITLE Partner <br /> SIGNEV <br /> 1 i DRAW PLOT LAN ON REVERSE SIDE <br /> FOR PARTMENT USE ONLY <br /> i PHASE I <br /> APPLICATION ACCEPTED B <br /> ' ADDITIONAL COMMENTS: <br /> PHASE .II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> --CALL-FOR A GROUT-INSPECTION-PRZOR•TO GROUTING AND FINAL INSPECTION. x/73 <br /> a v ii.oc - <br />