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ivrn- IV6 AOT AA1 <br /> SAN JOAQUIN LOCAL HEALTH DI ` <br /> OFOF h OF ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ©16F <br /> Telephone: (209) 466-6781 µ , 7 / <br /> APPLICATION FOR WELL CONSTRUCTION OR PLTNP PERMIT Permit No. ?�- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE'ISSUED Date Issued X-c20 7, <br /> (Complete In Triplicate) <br /> Apunty <br /> plication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> ' d/or install the .work herein described. This application is made in compliance with San Joaquil <br /> Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> lOB ADDRESS/LOCATION 600' oo ccof .Roa & .6 Mile East Duncan 8d. CENSUS TRACT los t+� zrS <br /> er'a Name V & A Lagorio Phone <br /> Iddress 18601 Tobacco Road, Linden, Calif. 95236 City" <br /> :ontractor's Name Purviance Drillers,P.O.Box 64,Linden;Calif. License A X0107 Phone 931-4468 <br /> 952 <br /> CYPE-OF WORK (Ch€ck)Ey NEwwELv Z- DEEPENT/z_T` RECONDITION /_W' DESTRUCTION /7 <br /> ' -PUMP INSTALLATION /_/ PUMP REPAIR -7 PUMP REPLACEMENT /7 {N <br /> Other / 7 <br /> )ISTANCE TO NEAREST: SEPTIC TANK 600l ' SEWER LINES PIT PRIVY <br /> ' SEWAGE DISPOSAL FIELD 600' CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL'., PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial a Cable Tool Dia, of Well Excavation SlastiXg 1.40 <br /> Domestic/private Drilled Dia. of Well Casing Inst. 1,211 1.1ner <br /> .Dome-sticjpublic Driven Gauge of Casing <br /> )z ":.'tIrrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By. 14 <br /> ■'UMP INSTALLATION: Contractor <br /> _r;y I116ra <br /> Type of Pump Za_Tn3'hrne. A.P. 50 <br /> LUMP REPLACEMENT: /% State Work Done <br /> 'UMP :REPAIR:. /7 . State Work Done <br /> ES,T� RUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure• <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> ind the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> Cfter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> ELL DRILLERS REPORT of the well and notify them before putting..the..well. in.use.... The above <br /> reformation is true to the-best of. my knowledge and belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> 'RIOR TO GROUTING AND A FINAL INSPECTION. <br /> IGNED i TITLE Partner <br /> (DRAW PLOT PLAN,ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> HALE I � <br /> PLICATION ACC);PTEll BY <br /> %DDITIONAL COMMENTS: - <br /> PHASE I GROUT INSPECTION PHASE IIF FINAL INSPECTION--„�. <br /> 'ENSPECTION BY� (�� ITE 23JSPECTION BY--W, DATE <br />