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SAN -JOAQUIN LOCAL HEALTH-DISTRICT <br /> LTH-D STRICT <br /> FOR OFFICE USE: . 1601 E. . Hazelton Ave. , , Calif. <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMITPermit No. S-- <br /> THI PERMIT EXPIRES 1 YEAR FROM DATE :ISSUED <br /> Date Issued <br /> (Complete In Triplicate) <br />' Application hereby trade tothe .San Joaquinl�oaallicatiori ismade inHealth District rco pliancea permit twithnSan Joaquin <br /> and/or install the work herein described. Th pp <br /> County Ordinance No. 1862 and the Rules and Regulationsfof,the San Joaquin Local Health District• <br /> CENSUS TRACT <br /> � O , <br /> JOB kDDRESS/LOCATION ! <br /> Phone <br /> owner's Naive Leno Lavagnino <br /> city Stockton <br /> Address 9541 Cole Drive <br /> Jars License # 21+0107 phone 931 <br /> LUTDrillers <br /> 6 <br /> Contractor's Name PViallCe Dr3.l <br /> • NEW WELL / I DEEPEN ./ / RECONDITION I IpESTRUCTIONNT? s <br /> TYPE OF WORK {Check) . <br /> PUMP INSTALLATION / I PUMP REPAIR I PUMP REPLACEMEI <br /> Other / / <br /> SEWER LINES PIT PRIVY <br /> DISTANCE TO .NEAREIT: , SEPTIC TANK CESSPOOL/SEEPAGE PIT OTHER <br /> p SEWAGE DISPOSAL FIELD PUBLIC DOMESTIC WELL <br /> PROPERTY LINE - <br /> PRIVATE PROPERTY WELL CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL <br /> . Cab1e_Tool :_,,� Dia:,�of ;We1lrExcavation ._ _.__ <br /> Industrial, ---�--- Z - . .__ . <br /> Dia. of Well Casing cr <br /> Domestic/private k'.,''� ' '� Drilled <br /> Gauge of Casing $ <br /> Domestic/public <br /> ..x Irrigation Gravel Pack Depth of Grout Seal <br /> Type of Grout ' <br /> Cathodic Protection Rotary Other Information;' <br /> Disposal Other _ c� <br /> GeophysicalSurface Seal Installed B M <br /> PUMP INSTALLATION: Contractor purviance Drillers Drilling Cor r <br /> ur ine <br /> -Type, of Pump v <br /> PUMP REPLACEMENT: / / ' State Work Done ro <br /> ( PUMP .REPAIR: �I <br /> State Work Done pull, rebowl, re-install <br /> t Approximate Depth <br /> I . DES,TRUCTION OF WELL: Well <br /> Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin LOWithinFIFTEEN atDAYS <br /> f and the State of California pertaining to or regulating we the San Joaquin <br /> Local <br /> after completion of my work on a new well, I willhem bfurnisefore puttingathe.wellinuse.HeThehaboverict t <br /> k WELL DRILLERS REPORT of the well and not y <br /> information �is true to the best of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING D FINAL INSPECTION, Bill Purviance TITLE owner/President , i <br /> SIGNED �. <br /> t D W..PL T PLAN ON REVERSE SIDE <br /> FO DE TMENT JJSE ONLY <br /> I PHASE I DATE l <br /> ► APPLICATION ACCEPTED BY <br /> t ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION <br /> I PHASE I GROUT INSPECTION INSPECTION BY DATE 4.Z. , <br /> INSPECTION BY DATE <br /> � 3/76 29 <br /> F u 1G26 Rev. '1-74 <br />