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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: 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 Date Issued �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 /> /10 <br /> OB ADDRESS/LOCATION LOCATION gow <br /> r h Eight wile Fd, I dile East 'Tul 7-y Rct• CENSUS TRACT <br /> Owner's Name aim. H. Williams Phone <br /> Address 8600 N. Clements Road, T.inden, Calif,. 95236 - - City <br /> Contractor's Name Purviance Drillers P.O.Box-64 Linden Calif. License # 240I07 Phone 931-4468 <br /> 952 <br /> i <br /> -TYPE-OF WORK (Check)-:-=NEW=WEL-L 'DEEPEN-/- -=-RECONDITION'=/-=/=`"DESTRUCTIONz`/=7 <br /> PUMP INSTALLATION '/i/ PUMP REPAIR / / PUMP REPLACEMENT 1-T . <br /> Other / / <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 1 <br /> INTENDED.USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ] <br /> Industrial Cable Tool Dia. of Well Excavation ; <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing �f <br /> x Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection . Rotary Type of Grout <br /> Disposal Other Other Information v � l <br /> Geophysical 1 , . Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Purviance Dril-lens <br /> ,Type of Pump 4trbine - - - - H.P. i40 ' <br /> U. <br /> nst a 1.1. pump an existing iv ej .-1 <br /> PUMP REPLACEMENT: . /�/ State Work Done �! <br /> PUMP .REPAIR: / / State Work Done <br /> DES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure i <br /> I hereby agree to comply with all{laws -and regulations of the'rSafi``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 anew 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 l <br /> PRIOR TO GROUTIN A FINAL INSPECTION. <br /> SIGNED TITLE Partner <br /> DRAW PLT PLAN ON REVERSE SIDE <br /> FOR:DEP:4RTMENT�USE-ONLX,-- <br /> -W- <br /> PHASE I _ n <br /> APPLICATION ACCEPTED BY `- ` -' DATE <br /> ADDITIONAL COMMENTS: _ J - <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ew DATE 3 - '7 <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 F <br />