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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 <br /> t (Complete In Triplicate) <br /> Application is4hereby 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 /> 173 2,0 09 . 6 rZ-iq7-- " ,4 . "J = b fit- rG0 - 02-- <br /> JOB ADDRESS/LOCATION .1 Mile north of Comstock 2j _200t R^„��y�r��rSPA TRACT <br /> Owner's Name Dei. Gotelli. Phone <br /> Address 9425 X, Askley City Stockton <br /> Contractor's Name i�urviance Drillers License #2107 Phone 931.-4468 <br /> � i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN '/ / RECONDITION /-7 DESTRUCTION /-7t W <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / rebewlinp, to change horsepower - -- (D <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD - ,-.--CESSPOOL/SEEPAGE PIT OTHER �1 <br /> PROPERTY LINE - PRIVATE ,DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool I Dia, of Well Excavation <br /> Domestic/private Drilled r Dia, of Well Casing <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 /> PUMP INSTALLATION: Contractor 1 urvianCc Drillers <br /> Type of Pump turbinp. kWaS 25 II H.P. 30Hk _ <br /> PUMP REPLACEMENT: pI / State Work Done chafing bowls to 3OH"F <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 rue °to the.best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTI G ANVA FINAL INSPECTION. <br /> SIGNED t BA-1ryiance TITLE pj.,Me, r p a id Ant <br /> DRAW PLOT PLAN ON REVERSE SIDE) I' „ <br /> OR PARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATE G g <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br /> 3/76 2M <br />