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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: ap 1601 $. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 's7 35 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Compl:ete In Triplicate):, <br /> Application is hereby made to the San Joaquin Local Health Dis.trict .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 75' North Frazier Rd. & Mi1_e East Clements Rd. CENSUS TRACT <br /> Owner's Name John Lewe1an Phone <br /> 1 <br /> Address 8742 N. G1.ement s Road Linden, Cal if. 95236 City <br /> Contractor's Name Pur�risnce 7ri1.1_ers,P.O.Box 6l�;Lind�,Cal.if.License # 21,.0147 Phone 93 -[,1:68 6 <br /> 9 5236 <br /> i <br /> -TYPE OF-WORK- (Check)-: NEW=WELL / / DEEPEN RECONDITION /_/ DESTRUCTION I .- <br /> PUMP INSTALLATION /X/ PUMP REPAIR / / PUMP REPLACEMENT / T <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK . 8 idi.SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 3/8 Mi.CESSPOOL/SEEPAGE PIT �- OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> t INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> x Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> DisposalOther Other Information <br /> Geophysical -T Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Purviance Drillers LL <br /> Te of Pump `Turbine H.P. _50 <br /> �Ilnstal_!_ .pump �n axis ung e <br /> PUMP REPLACEMENT: / / State Work Done , <br /> r. - <br /> 1'UMP .REPAIR._ Srate_Work.Donees_ <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 an 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 we11 and` notify thei before -putting the. well 'in use. The above <br /> information is true to the-best of my- knowYedge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTIN AN FINAL INSPECTION. - <br /> SIGNED TITLE <br /> T P.L0_ N-REV.ERSE_'..SID _ -- <br /> FOR DEPARTMENT.`USE=ONLY <br /> F PHASE I ` DATE <br /> APPLICATION ACCEPTED BY - <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE ON <br /> III/FINAL INSPECTI <br /> INSPECTION BY DATE INSPECTION BY DATE /� � ` <br /> 3/76 <br /> I E H 1426 Rev. 1-74 <br />