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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F01_OFFICE USE: 7X1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> i <br /> THIS PERMIT EMPIRES 1 YEAR FROM DATE.ISSUED Date Issued -56, <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 <br /> in withJoaquil <br /> k County Ordinance .No. 1862 and .the Rules and Regulations of the San JoaquinpLocal eHeal,th$an District. <br /> JOB ADDRESS/LOCATION 4 Mi. East C7,ements & S Mi. North Comstock 1 CENSUS TRACT <br /> Owner's Name Wm. H. Williams Phone <br /> Address 8000 N. Clements Road, Tinden;- Calif, City <br /> Contractor's Name Furviance Drillers P.G.Rox 64 Linden Ca7;if. � <br /> License ' 2�0-xG7 Phone 93ll ,6$ <br /> TYPE OF WORK (Check):. NEW WELL DEEPEN '/? RECONDITION / f DESTRUCTION{f7 ' <br /> PUMP INSTALLATION -/—/ PUMP REPAIR -/-7—pump REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 701 (SEWER LINES ' <br /> PIT PRIVY � <br /> SEWAGE DISPOS _ IELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY, LINE!,-''PRIVATE DOMESTIC�.: WELL '— PUBLIC .DOMESTIC WELL INTENDED USE �.; TYPE OF-WELL CONSTRUCTION SPECIFICATIONS t <br /> Industrial• x Cable Tool Dia. of Well. Excavation 8 <br /> x Domestic/private' .y_. : ' ,; Dr llecl`s b:..�x Dia-i- of--We112Casiaig� ` a 811.—_.. <br /> y Domestic/public Driven,E~ Gauge of Casing 0 <br /> i <br /> Irrigation$ Gravel -tack Depth of Grout Seal, 521. <br /> " Cathodic Protection Rotaryai) Type of Grout meet Cement <br /> O <br /> Disposal <br /> p _ ther _ Other Information , <br /> Geophysical —surface Seal Installed <br /> � <br /> B � <br /> PUMP INSTALLATION. .Contractor <br /> Type .of Pump - a-- �-- <br /> �,k. . A.P. -- <br /> PUMP REPLACEMENT: /x/ -.,SPatl-Work Done Fie-instal], 1,0 QIP Turbine <br /> PUMP,-REPAIR: "' 'y� / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 1 .. <br /> Approximate Depth ' # '. <br /> Describe MateriaV and Procedure ' <br /> tI 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 , I will furnish the San Joaquin Local Health District'a <br /> WELL DRILLERS REPORT-of� h�e twell and"uotify them before putting the.-well in.use.... .The above <br />' information is true to the-best of my. knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br />'.PRIOR TO dROUTING A FINAL INSPECTION. <br /> FSIGNED _ - <br /> TITLE Partner f <br /> {DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE Il GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY_ DATE <br />� ~E H 1426 Rev. 1-74 <br />