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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- <br /> ?7_,y6 a10 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued L-77 <br /> (Complete In Triplicate) f <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 1,5001 South of Turner Road & 1-25701 Wes of DavisCENSUS TRACT DSS- 14-0--1f � <br /> r <br /> Owner's Name Don Reynolds Phone <br /> Address 505 S. L'iain, Lodi, Calif. 95240 City <br /> Contractor's Name Furviance Dri!7ers,Box_641Lindeg,Cal if-..g5236License # 240107 Phone 231.-1,�b$ <br /> TYPE WWORK (Check) : NEW WELL /X/ DEEPEN / / RECONDITION�/, 7 DESTRUCTION /_7 <br /> PUMP INSTALLATION /X / PUMP REPAIR / / ,PUMP REPLACEMENT <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC TANK 21000' SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD ' CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE M PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial x Cable Tool Dia. of Well Excavation 1.6" <br /> Domestic/private Drilled Dia. of Well Casing Io'� <br /> .._ .Domestic/public Driven ­,-_­GaugeGauge of- Casing 3L16" Plate' <br /> x Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary ..Type of Grout <br /> -Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> F <br /> PUMP INSTALLATION: Contractor ;rurviance Drille' rs <br /> Type of 'Pump Turbine H.P. L0 <br />' PUMP REPLACEMENT: . / / State Work Done <br /> PUMP REPAIR: State-Work Done - <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <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 /> i <br /> information is true to the best of my..knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND_A.4INAL INSPECTION. Partner j <br /> SIGNED ,) TITLE <br /> DRAW PE T PLAN ON REVERSE SIDE <br /> I <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE .� I <br /> ADDITIONAL COMMENTS: <br /> PHASE ZI GROUT. INSPECTION " PHASE III] <br /> ,F <br /> jNALINSPECTION <br /> INSPECTION BY DATE INSPECTION BY � - DATE <br /> E H 1426 Rev. 1-74 376 2M <br />