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SAN JOAQUIN LOCAL HEALTH DISTRICT 5 <br /> FOEZFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.77-f,�9-5 <br /> f THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /O.--21-77 <br /> / rj i :'ce'�fo,Aaccs + (Complete In Triplicate) ,,Jr <br /> r <br /> Application- le hereby,` de 'to the' San Joaquin Local llealth District for a permit to construct <br /> and/or install-the wort herein described. This application is made in compliance with San Joaquit <br /> '' County rdinance No 1662 and the Rules and Regulations of the San Joaquin Local. Health District. <br /> hM. DIYV CATION 400' South Copperopoli.s Rd. & 1.1 Mile West Mormc,4 CENSUS TRACT <br /> 00ner's Name Gordon ICC07 Phone <br /> Address 87 Hi 7 or Drive flak?a> Ca?if. i <br /> City . ' <br /> Contractor's Name Purviance Drillers P.O.Box 64.,Tinden,Cal.1'f. License # 240107 Phone 931-4468 �-- <br /> . <br /> j] <br /> TYPE-OFA-WORK (Check): --INRW -WELL- 1/-x7---DEEPEN--/-7,—RECONDITION--/_-7 -DESTRUCTION f7---' -- <br /> UMP INSTA71LA IO X/ PL* REPAIR -/-7 PUMP REPLACEMENT / <br /> a0ther <br /> DISTANCE_,TO-NEAREST: - SEPTIC-TANK-. - --SEWER-LINES- ;PRIVY <br /> I: <br /> !SEWAGE DISPOSAL .FIELD CESSPOOL/SEEPAGE PIT OTHER w: <br /> -T P' QPERTY`LIFE =°PRIVATE DbMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE i TYPE OF WELL ' ',; f CONSTRUCTION SPECIFICATIONS <br /> Industrialx Cable Tool ;Dia. of Well Excavation Z Q <br /> X Domestic/private Drilled i Dia. of Well Casing 10" <br /> Domestic/public Driver: w=Gauge of Casing 10 <br /> Irrigation Gravel. Pack Depth of Grout Seal 501 . <br /> A Cathodic Protection Rotary Type of Grout Neet Cement T <br /> Disposal ,- Other Other Information -W, onduc or;; pe, <br /> Geophysical . Surface Seal Installed By: <br /> Yas- <br /> PUMP INSTALLATION: , contractor Purviance Drillers <br /> Type .of Pump Submerall2a A.P. �5 <br /> 4 , <br /> PUMP REPLACEMENT: %/ State Work Done <br /> PUMP 'REPAIR:,,_._ <br /> �!/B.,S.tAte Work_Done - - <br /> � <br /> DESTRUCTION OF WELL: ell Diameter Approximate Depth <br /> Describe Material and Procedure z <br /> .7 <br /> I hereby agree to comply, with all laws and regulations- 6f the San -Joaquin Local Health District <br /> and the State of California pertaining to or regulating well "cons FIFTEEN DAYS <br /> after completion of my "'' rk on a new well, I will furnish the San Joaquin Local Heal.th,.District a <br /> WELL DRILLERS REPORT of,, the well and notify them before putting-. the..well. in use... The above <br /> information is true tothe-best-of- my knowledge and belief. I WILL CALL�FOR`A'GROUT INSPECTION <br /> PRIOR TO GROUTING 'AND ATINAL INSPECTION. <br /> SIGNED TITLE Partner <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �! <br /> APPLICATION ACCEPTED BY; j- DA g IfJ- X8'77 <br /> 3 ADDiT.IONAL COMMENTS: - <br /> .r PHASE II GROUT INSPECTION P E AOUINAL INSPECTION <br /> 1 INSPECTION BY 11 DATE // v-77 INSPECTION BY DATE -5-:- <br /> i E H 1426 Rev. 1-74 rr h/75 <br />