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FOR�rOF '10E USE: ' SAN JOAQUIN LOCAL <br /> 160.1 E. HEALTH DISTRICT <br /> Hazelton Ave.HE, Stockton _] <br /> Telephone: Calif. / <br /> r <br /> APPLICATION FOR WELL CONSTRIdCTION60RlPUMP PERMIT <br /> F THIS PERMIT EMPIRES 1 y Permit No. '--7— V. <br /> Application ie hereby ' FROM DATE ISSUED '--�-' -_ <br /> I y made to the San (Complete <br /> Local Iealth Triplicate) <br /> � Date Issued rI/a -77 <br /> and/or install the work herein described. <br /> This County Ordinance No. 1862 and the Rules 'and Regulation et for a permit to construct <br /> application is made in co <br /> Regulations of "he San JoaquinpLo alianceHealth District. <br /> with San Joaquin ,: <br />- . dOB ADDRESS/LOCATION 350' South <br /> L�.ve Oak Road & �- Nile East <br /> Owner's Nam r 99 Fromta�ENSUS TRACT <br /> Eu ene ?.,ind <br /> Address5324 EPhone <br /> E. Live Oak Road Lodi , Ca <br /> } <br /> lzf. 95240 <br /> Contractor's Name Purviance Dri1_?ers P.0 Box 6 City <br /> 4 Linden Calif* License # r <br /> 952 '0. xE3'7 Phone 937 <br /> TYP$�OF WO�(Ch�e - <br /> NEW WELL AFT DEEPEN _/-7 <br /> " K ' <br /> PUMP INSTALLATION CONDITION /? DESTRUCTION /-7 <br /> Other / // PUMP REPAIR / /I PUMP REPLACEMENT <br /> - AF In <br /> DISTANCE-TO-.-N <br /> -T <br /> SEPTiC ANK " �i_ es . � ' r l 4• '� <br /> ` SEWAGE DSKOSA TIE-S�R LINES = - - PIT_PRIVY <br /> CES <br /> ' PROPERTY .LINE - PRIVATE DOMESTICSPO WELL- <br /> PIT`_ OTHER <br /> INTENDED USE TYPE OF WELL PUBLIC DOMESTIC WELL <br /> -` <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> DOmeStIc/private �-- Cable Tool Dia. of Well Excavation �+ ' <br /> Domestic ____�_ Drilled <br /> /public Dia. of Well Casing �, f <br /> z Irrigation -.____ Driven Gauge of Casing _ <br /> �_ Gravel Pack Depth of Groutseal <br /> Cathodic.P.rotection _ Rotary <br />—Disposal., - Other rout <br /> of Grout <br /> Geophysic�aal "�,.4 � -----.-._� Dther•Informatian_ .� <br /> Surface,Seal Installed B <br />?UMP INSTALLATION: Contractor . <br /> Type of Pump �.. <br /> H.P. <br />'UMl'iREPI,ACEMENT; t.� / � State Work Done <br />'UMP :REPAIR: V / - -State-Work Done <br /> ES RUCTION OF WELL: Well Diameter T <br /> Describe Material and Procedure Approximate Depth <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> nd the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> Iter 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 Puttingthe -well in use. The above <br /> aformation is true to the-beat of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> tIOR TO GROUTIN A FINAL INSPECTION. <br />[GNED <br /> (DRAW PLOT PLAN ON REVERSETSIDE LE Partner <br /> iASE I FOR DEPARTMENT USE ONLY <br />'PLICATION ACCEPTED BY <br /> 1DITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION PHASE III, __NAL INSPECTION <br /> lSPECTION BY DATE INSPECTION $Y <br /> DATE 3-30 -7 <br /> R H 1426 Rev. 1-74 <br /> - 9_7.. nu <br />