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1 ✓ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 7Oz.761 ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> f APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2_,x.- 1 U� <br /> THIS PERMIT EXPIRES 1-YEAR FROM DATE 'ISSUED Date Issued i__2z_. <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. 1852 and the Rules and Regulations of the San Joaquin Local health District. <br /> le-3 2oQ -C),? <br /> JOB ADDRESS/LOCATION Mi.. South Copperopolls L Mi. West Duncan CENSUS TRACT <br /> r Owner's Name R & J Dondero Phone <br /> Address x.6299-E. E!� 26; Linden, Calif. , City <br /> Contractor'`s Name Furviance Drillers, Box 64, Linden License # 240-107 Phone 931•-4468 <br /> � � W <br /> TYPE OF-WORK (Check),:-= NEW-WELL / /a DEEPEN-.:/.-til= RECONDITIONrl_/= DESTRUCTION <br /> � PUMP INSTALLATION 4/ PUMP REPAIR / / PUMP REPLACEMENT /� �`� <br /> ;r Other <br /> t' <br />' O <br /> DISTANCE TO'NEAREST: - HPTI-C-TANK 3 jbli$EWER LINES PIT PRIVY A_ rt� <br /> SEWAGE DISPOSAL FIELD '� CESSPOOL/SEEPAGE'PIT — `1 "OTHER�, <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial x Cable Tool Dia. of Well Excavation 16" <br /> Domestic/private Drilled Dia. of Well Casing b" � <br /> Domestic/Public Driven Gauge of Casing _ 3 1b" date <br /> x Irrigation Gravel Pack Depth of Grout -Seal:" none <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor Furviance Drillers I <br /> Type of Pump Turbine H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> •DFgTRUCTION OF WELL: Well' Diameter Approximate Depth <br /> PP P <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. <br /> SIGNED TITLE Farther <br /> f. (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR ARTMENT USE ONLY <br /> PHASE I <br /> f# APPLICATION ACCEPTED .BY fi(/:. DATE �f - 7 f <br /> r_ ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P �I/ INAL INSPEC ION <br /> INSPECTION BY DATE INSPECTION BY DAT <br /> -- CALL-FOR-A-GROUT-INSPECTION.PRIOR -TO GROUTING-AND FINAL-INSPECTION. r <br /> E .H 1426 5/731M i '. <br />