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Poll-SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> • Telephoner (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7_Z___9_Z_1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued a y-72 <br /> (Complete In Triplicate) A"*10, t- 1'(-0-Z-7 <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 /> _4=r&j-c ,.-trc,4-;-0 Mi Road <br /> 30B ADDRESS/LOCATION i-4�10 Pile West Jack Tone & 6 10 Mile South Eight cE��US TR�CT <br /> Owner's Name Dan Brandstad Phone <br /> Address 11090 E. Baker Road, Stockton, Calif. 95205 City <br /> Contractor's Name Purviance Dril Jers,Box 64,Linden,CO�f.95236License # 240`T07 Phone X931.-4.4.68 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_7 'RECONDITION_)F/ DESTRUCTION /7 <br /> PUMP INSTLATION -/!/ PUMP REPAIR / / PUMP REPLACEMENT /? <br /> AL <br /> Other 'f_1 <br /> DISTANCE TO NEAREST: SEPTIC TANK 7-0 .. 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 x Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> X Irrigation Gravel Pack4 Depth of Grout Seal <br /> Cathodic Protection Rotary Type of- Grout <br /> Disposal Other Other Information lean out ins ner . <br /> Geophysical Surface Seal Installed By:- <br /> PUMP <br /> :PUMP INSTALLATION: Contractor Purviance Drillers <br /> Type of PH.P. <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 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-beat of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION.. <br /> PRIOR TO GROUTING1 AWA FINAL,INSPECTION. <br /> SIGNED TITLE77 <br /> D W ' PLAN '0N RE $SE SIDY5 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE -7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE JAItAINAL INSPECTIOW. <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 3,/76 <br /> E H ,1426 Rev. 1-74 <br />