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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 4�7 <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_2 Mile north of- $Mile Rd} north bank of _ - CENSUS TRACT <br /> CalaveraS River <br /> Owner's Name no nobenzi Phone <br /> Address 12267 E. Eight Mile Rd city Stockton <br /> Contractor's Name Purviance Drillers License # 240107 Phone 931-4468 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN RECONDITION RECONDITION_/_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT (K� <br /> Other l I N <br /> . N <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 /> Domestic/private Drilled Dia. of Well Casing all <br /> Domestic/public Driven Gauge of .Casing <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 /> i <br /> PUMP INSTALLATION: Contractor Purviance Drillers <br /> 40 <br /> Type of Pump Ur bine H.P. <br /> PUMP REPLACEMENT: /g/ 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-best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTINQ AM A FINAL INSPECTION. JA <br /> SIGNED Bill Purviance TITLE owner/President <br /> a DRAW P-L T PLAN ON RE ERSE SID-E-5 <br /> FOR DEPART NT USE ONLY <br /> PHASE I 17 <br /> APPLICATION ACCEPTED BY DATE L <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION , <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> •• . 3/76 2M <br /> E H 1426 Rev. 1-74 <br />