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` L SAN JOAQUIN LOCAL HEALTH DISTRICTj,l�� <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. G Y <br /> Telephone : (209) 466-6781 7 7_/ (f7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <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 3000 Durham Ferry Rd. CENSUS TRACT <br /> Owner's Name Bill Fisk Phone 835-4599 <br /> Address P.O. Box 814 City _Vernalis. Ca. <br /> Contractor's Name Stanislaus Pump License A290355 Phone 522=90.27 - <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/_7 DEEPEN-/�/ RECONDITION / / DESTRUCTION /� y <br /> PUMP INSTALLATION/ /:` PUMP REPAIR / / PUMP REPLACEMENT <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 /> x 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 <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Stanislaus Pump <br /> Type of Pump Submersible H.P. <br /> PUMP REPLACEMENT: /x/ State Work Done _ Replace pump - <br /> PUMP -REPAIR: /7 State Work Done <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 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. I WILL CALL FOR A GROUT INSPECTION <br /> OR Ga9UTING AN FINAL INSPECTION. <br /> SIGNED ! ITL C1G�t�✓ <br /> DRAW PL T PLAN ON RE ER -E S� DE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I / --7'7APPLICATION ACCEPTED BY DATE li <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIIUTNAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DAT 7 <br /> E H 1426 Rev. 1-74 ' 3/76 2M <br />