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SAN JOAQUIN LOCAL HEALTH-DISTRICT <br /> FOE OFFICE USE: <br /> J6 1601 E. Hazelton Ave. , Stockton, Calif. <br /> - Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued /_ 7� <br /> {Complete In Triplicate) <br /> Application is hereby made to the San Joaquin ThisoapplicationapHealth istrict for a made in co plianceit twith SanJoaquin <br /> and/or install the work herein described. <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION .4 'Mi• ,Forth Eight mi16 Road &'j bpi. East Jack ToadENSUS TRACT <br /> Phone <br /> Owner's Name Reno. Paoletti <br /> Address ' 3881 Easy-.Eight N;i7.e Road Stockton Ca 1 if.. <br /> City <br /> Contractor's Name Purviance Dxi1_1ers Bow b4 T,inden ,.�.f. License # 2(,.0-1fl7 Phone <br /> �6�. <br /> 931- <br /> TYPE OF WO {Cheek) : NEW WELL- <br /> -- 17,T-DEEP 'RECONDITION /XT DESTRUCTION / <br /> PUMP INSTALLATION / <br /> PUMP REPAIR / / PUMP REPLACEMENT I?s� <br /> Other <br /> k2 } <br /> DISTANCE TO NEAREST: SEPTIC TANK 50Q! SEWER LINECESSPOOL/SEEPAGE PIT PIT PRIVY OTHER <br /> ` SEWAGE DISPOSAL FIELD <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE F WELL <br /> CONSTRUCTION SPECIFICATIONS � <br /> TYPE O <br /> x Cable Tool Dia. of Well Excavation <br /> Industrial g_ <br /> � � Dia. of Well Casin <br /> a Domestic/private _ .Drilled -r s 3`r <br /> Domestic/public.. <br /> Driven Gauge4of Casing <br /> Irrigation `' '. Gravel. Pack Depth of Grout Seal- <br /> Cathodic Protection - Rotary Type of GroutF, Other Information C 07% on'� Sand & Irist.Iine <br /> Other <br /> .Disposal . -- ----- <br /> Surface Seal--Installed 'B :---` <br /> Geophysical" <br /> PUMP INSTALLATION: Contractor H.P. <br /> k Type of Pump - \ <br /> PUMP REPLACEMENT: /x/ State Work Dona Rep7_ace existing Submersible tam <br /> t PUMP ,REPAIR: j / State Work Done _ <br /> Approximate Depth, { ' <br /> DESTRUCTION OF WELL: Well•Diameter j ter. <br /> Describe Material and Procedure <br /> ith all laws and regulations of . he San Joaquin Local Health-District <br /> I hereby agree to comply w <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> I wi11 furnish <br /> after completion of my work on a new well, <br /> utinSathe�wellninouse.HeThe�,aboverict <br /> WELL DRILLERS REPORT of the well and notify them beforeputting <br /> information is true to the best of MY.knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTIN A FINAL INSPECTION. <br /> TITLE Partner „1 <br /> SIGNED , :.. <br /> C � PLAN �ON ERSE SIDE ,i <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL ,COMMMS: PHASE IIY/FINAL INSPECTION` . <br /> PHASE II GROUT i1QSPECTION INSPECTION BY DATE <br /> INSPECTION BY DATE -----�—� <br /> --�-�- <br /> �r,� -,7 <br /> 3/76„ 2M <br /> E H 1426 Rev._l-74,..--­- . <br />