Laserfiche WebLink
66 <br /> w SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -1,59djO <br /> p <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM 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.., x.862 and -the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB'ADDRESS/LOCATION Mi. West Clements Rd. & Mi. South Brandt Rd.i CENSUS TRACT <br /> Owner's Name John Bree Phone - <br /> 4 . <br /> Address _ _ 6948 ArrowwoodyDrive, Modesto, Calif...' City <br /> IContractor's Name Purviance Drillers Box 64, linden, Calif. License # 240-107 Phone 93'x-4468 <br /> TYPE...OF_WORK_(Check)*.___NEW-WELL /-.7- 1DEEPEN.-/77--YRECONDITION -17 DESTRUCTION r7 - <br /> PUMP INSTALLATION /x/ PUMP REPAIR '/7 PUMP REPLACEMENT 17 <br /> F Other J / <br /> x <br /> DISTANCE TO NEAREST: SEPTIC TANK m3- ' SEWER LINES mY PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTiC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF. WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial t n; Cable- Took. Dia. of Well Excavation <br /> Domestic/private Drilled, Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing —' -•- <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary•- Type,;of,-Grout <br /> Disposal Other Other Information <br /> Geophysical - -- Surface Seal Installed 'By , . ._ .. _. <br /> PUMP INSTALLATION: _ Contractor _Purvignee Drillers <br /> f Type of Pump - Turbine H.P. 40 HP <br />` PUMP REPLACEMENT: . / / State Work Done <br /> i <br /> PUMP .REPAIR: / / 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 REPO of a 11 and notify them before putting.. the..well. in use... -The above <br /> informat is t e to th •bes of my.knowledge and belief. I W L CAL FOR A 'GROUT INSPECTION <br /> PRIOR T GROU N NAL NSPECTION. <br /> SIGNED TITL <br /> *� <br /> IV (DRAW PLOT PLAN ON REVERSE S <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY All DATE , <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE UI/PXNAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> # t H 1426 Rev. 1--74 .,- .^ U75 2M. <br />