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l SAN JOAQUIN LOCAL HEALTH DISTRICT --- J <br /> FORfOFFI,CE USE: ,1601 E. Hazelton Ave. , Stockton, Calif. 1 v <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 <br /> I THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued a 71 <br /> (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 he Ru es and Regulations of the San Joaquin Local. Health District. <br /> JOB ADDRESS/LOCATION 401 South Live Oak Road . Nike West Angier Road CENSUS TRACT <br /> Owner's Name Bob Caffese Phone <br /> Address 64 E. Live Oak Road Lodi Calif, City <br /> Contractor's Name Purviance Drillers P.O.Pox 64,I:ind6nl Calif.License #240T07 Phone 931-"68 <br /> F TYPE OF WORK (Check): NEW WELL ,/-7 DEEPEN A-7 RECONDITION DESTRUCTION /_7 <br /> PUMP INSTALLATION../—/ PUMP REPAIR /-7—pump REPLACEMENT f <br /> Other /_7 — <br /> DISTANCE TO NEAREST: .. SEPTIC TANK 2001 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 2001 . CESSPOOL/SEEPAGE PIT OTHER <br /> ,-PROPERTY LINE - PRIVATE DOMESTIC WELL'—' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrialx Cable Tool Dia. of Well Excavation ng <br /> Domestic/private Drilled Dia. of Well. Casing Inst, 12" Liner <br /> Domestic/public Driven Gauge of Casing -y p' <br /> X. Irrigation Y Gravel Pack_ - 7epthy of Grout Seal � <br /> Cathodic Protection Rotary Type of Grout ^ � <br /> Disposal Other Other Information <br /> Geophysical Surf -- � . <br /> ace Seal. Installed By., <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /_7 State Work Done y <br /> k <br /> PUMP :REPAIR: /7 State Work Done, <br /> ES-TRUCTION 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 D A FINAL INSPECTION. <br /> SIGNED TITLE Part <br /> ner <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY - <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: //�-� -7)• <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY p .— DATE <br /> 4 ~E H 1426 Rev. 1-74 <br /> - - 1-74 2M <br />