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SAN JOAQUIN LOCAL HEALTH DISTRICT ° <br /> FOE;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _77`I;LV Y <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6 I`ll <br /> (Complete In Triplicate) <br /> Application is'hereby made to the Says 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 Joaquit <br /> County Ordinance No. '1662 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION -4 Mile East Clements Rd. & .4 dile North Comsto <br /> * SUS TRACT . <br /> Owner's Name %ebster 'Ranch Phone ; <br /> Address 8742..N. Clement .Road, Linden, .Calif. 95216 <br /> � city: . <br /> Contractor's Name Purbiance Dxi lers P.O.Box 64 Limen Calif. License # - 240107 Phone 93!-"68 <br /> 952 <br /> TYPE OF WORK (Check) : NEW WELL a - f <br /> ( , /� DEEPEN /? RECONDITION /S7 DESTRUCTION %f <br /> PUMP INSTALLATION / / PUMP REPAIR/_7PUMP REPLACEMENT __y <br /> Other /% <br /> DISTANCE TO NEAREST: SEPTIC TANK,� SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ' PROPERTY LINE -- L DOMESTIC WELL PUBLIC DOMESTIC WELL N <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS U <br /> Industrial xCable Tool Dia. of Well Excavation Existing 1 <br /> C' Domestic/private Drilled Dia. of Well Casing Inst. 1,211 Liner � <br /> Domestic/public Driven Gauge of Casing ZQ <br /> ' Irrigation Gravel Pack Depth of 'Grout :Seal <br /> Cathodic Protection Rotary Type of Grout ` <br /> Disposal Other Other Information ' <br /> Geophysical <br /> Surface_Seal Installed 'By: <br /> PUMP INSTALLATION:\-, Contractors , "A' � <br /> Type .of Pump _ H.P. <br /> PUMP REPLACEMENT: . j_/ State Work Done <br /> i. PUMP :REPAIR: - / / State Work Doane <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. I WILL .CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING 'AMM,FINAL INSPECTION. <br /> SIGNED TITLE Partner -' <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> ! PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> - �� <br /> APPLICATION ACCEPTED ,BY DATE7 dl <br /> 77ADDITIONAL COMMENTS , <br /> PHASE 11 GROUT INSPECTION S PHASE IXI F. AL -INSPECTION <br /> kINSPECTION BY --_DATE INSP CTIIq <br /> ON BY DATE , 7 <br /> E 11 1426 Rev. 1--74 e� e�w -� vvv+ C"-:-A . It/7e, 9M <br />