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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOR OFFICE USE: 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 4666781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Z7-4,tf-y4 <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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 1.6360 E. Comstock Road (s/s Comstock, j Iii. E.Tu]_?Z'ENSUS TRACT <br /> Owner's Name David Miller Phone <br /> Address 20475 E. WaInut Drive, T,inden, Cal.if.'952316 City <br /> Contractor's Name Purviance Dril.'Lers,P.U.Box 64Jinden,Cs,7-�_f. License # 240107 Phone 93 `4468 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN RECONDITION RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP''INSTALLATION"/ / PUMP REPAIR`'/_/ PUMP REPLACRMENT /x <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 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 Cable. Tool 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 J <br /> Geophysical Surface Seal Installed By: <br /> i <br /> PUMP INSTALLATION. Contractor <br /> s <br /> _. . � _ ._.. <br /> Type-of_.Pump <br /> ..._..- r- H.P. <br /> PUMP REPLACEMENT: . /x/ `State Work Done Pull-existing Turbine ,Reinstall with neve bov-1 I <br /> PUMP .REPAIR: <br /> / / ' State Work Done <br /> DESTRUCT ON OF WELL. Wel 1"D ameter°� ��-- --.Appy-oximate-Depth:-._.-- <br /> - Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Dist ict <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 thewell 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 APDA FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PL T PLAN 'ON RE FRSE SIRE) - 7 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> _APPLICATION ACCEPTED BY SDATE <br /> ADDITIONAL C%ffiENTS: <br /> PHASE II GROUT I ECTION P E I/ INAL INSPECTIQN <br /> INSPECTION BY DATE INSPECTION BY DATE a t,z 7 <br /> 3/76 2M <br /> E H 1426 Rev. -1-74 <br />