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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Tele honer ' <br /> • p (209) 466-6781 <br /> 1 = APPLICATION FOR WELL CONSTRUCTION OR -PUMP PERMIT Permit No. <br /> THIS PERMIT •EXPIRES, 1 YEAR FROM DATE ISSUED Date Issued. i d <br /> ,Z(op77-� l�E.✓F.1EFrG ,�.� (Complete .In Triplicate) � _ Zpp�,p <br /> Application is hereby made to the San Joaquin Local Health District for P ermit 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 /> 250' W6 st of K*zmfl-sh Rd <br /> JOB ADDRESS/LOCATION, 4,/10 mile North of Co lie CENSUS'TRACT <br /> Owner's Name Troy Brooks Al <br /> Phone <br /> Address Rt. 2 Box -3633 Agampo City _ Acamp 4 <br /> Contractor's Name Purviance Drillers License #240102 Phone <br /> TYPE OF WORK (Check) : "` NEW WELL K DEEPEN / / RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 ' <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY. <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OZ WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Xx CableToolDia. of Well Excavation 14" <br /> Domestic/private Drilled Dia, of Well Casing Ift 14" .� <br /> Domestic/public Driven Gauge of Casing 10 a <br /> XX Irrigation Gravel--Pack Depth of Grout Seal -� <br /> Cathodic Prn otectioRotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor � <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> I-PUMP-.REPAIR: <br /> _ / / State Work Done -- -�• <br /> DESTRUCTION 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 FINAL INSPECTION: <br /> SIGNED TITLE Partner <br /> D W:PMT PLAN 'ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTEDBY DATE b"' <br /> ADDITIONAL COMMENTS: C2 ' <br /> PHASE II-GROUT. INSPECTION PHASE III/ INAL INSPECTION <br /> INSPECTION BY DATE _ INSPECTION BY DATE /'&, , <br /> }} <br /> EH 1426 Rev. 1-74 i 3/76 2M <br />