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7-- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FQFsiOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> T <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.------------ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7-7a ' <br /> �.2 .. . .ffrdyaJ (Complete In Triplicate) Ant ; 0P-7- fr�e� 2S <br /> A.pplicdtion"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 :Wade in compliance with San Joaquin ' <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> .3 mile W _of Boyer <br /> JOB ADDREss/LOCATION ,600s IN- of HW.y 88 _ - f CENSUS TRACT -- <br /> Owner's Name Mirs. Louise F?zzi Phone <br /> Address 5223 Waterloo Rd City Stockton <br /> Contractor's Name Purviwace Drillers License # 240107 Phone931-X46$:, <br /> TYPE OF WORK (Check): NEW WELL /7 DEEP " +/X RECONDITION 9--7 DESTRUCTION /7 <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other i z <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 XX Cable Tool Dia. -of ,Well Excavation <br /> Domestic/private Drilled Dia.-.o€ <We1VCasing 10 25 Baa <br /> Domestic/publicDriven _ Gau a of. C4iing�._._:_. _ <br /> X Irrigati6n . �y `Gravel Pack,\:, ,,,;, 'Depth of Grout Seal <br /> Cathodic-Protection -~-----��Rotary_. -,-- --_4—Type-;of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal. Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> 3 <br /> PUMP REPLACEMENT: / / State Work Done F <br /> . P <br /> State_WorkYDone�� __�_ a <br /> PUMP '.REPAIR: ---------- <br /> -L7 <br /> ,RE&TRUCTION 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 /> PRIOR TO GROUTI G A F NAL INSPECTION. <br /> SIGNED TITLE t artener <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR.DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ; rt , DATE TS S <br /> ADDITIONAL COMMENTS: '� ...-n• _. ,;., �s . i ; <br /> PHASE JI GROUT INSPECTION- '''"'"' P I FINAL INSPEC ON <br /> INSPECTION BY DATE INSPECTiQN BYegv DATE <br /> E H 1426 01H 21(j HTJA3F., -- <br /> 1-74 2 <br /> Rev. 1.-74 M ,� _ <br />