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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOV OF'KCE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (205) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> Ok THIS PERMIT EXPIRES 1 YEAR FROiy. DATE ISSUED Date Issued <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 the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 20080 E. Kettleman Lane Lodi CENSUS TRACT <br /> Owner's Name David A. Navone Phone 478-8429 (Stockton) <br /> Address 20080 E. Kettleman Lane, Lodi, Calif._ 95240_ _ City <br /> Contractor's Name . PURVIANCE DRILLERS, P. 0. Box 64, Linden License # 240107 Phone 931=Uda8 <br /> TYPE OF WORK (Check) : NEW WELL -57 DEEPEN '/ / RECONDITION /_T DESTRUCTION /-7 <br /> AL <br /> PUMP INSTALLATION /—Z/ -PUMP REPAIR/ / PUMP REPLACEMENT J—T <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 1270 SEWER LINES 120 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial x Cable Tool Dia. of Well Excavation 811 Well - 12R Seal <br /> x Domestic/private Drilled Dia, of Well Casing 8" 12n <br /> Domestic/public Driven Gauge of Casing 10 ga 12 pa <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout neat cem <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor Pure nae Drillers <br /> Type of Pump Submeraible _-.-- -- H.P. 3 <br /> PUMP REPLACEMENT: / / State Work Done 3 <br /> PUMP REPAIR: J / 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. <br /> SIGNED 4ZZc TITLE Partner <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 1 \ /`' DATE C� <br /> ADDITIONAL COMMENTS: <br /> PHAU II GROUT INSPECTION PHASE IIIJFINAL INSPECTION <br /> INSPECTION BY DATE7�'} INSPECTION BY i DATE �., - 70 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />