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a r y <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> l APPLICATION FOR 14ELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,e5'_ r� <br /> 76��®��� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> { <br /> ApplicatioA� is hereby made tin the Son 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. j <br /> JOB .ADDRESS/LOCATION 75' South of Fairchild Road &h .Mi. West of Jack ­CENSUS TRACT <br /> Tone ad <br /> Owner's Name Mary Kel.1 <br /> Phone ' � <br /> Address j P. 0. Box 586, Linden, Calif. 95236C1t <br /> D <br /> ti ., <br /> y.. . <br /> Contractor's Name Purviance �rilters, Box 64.,linde�n, Calif 'Cali;: License # 240-107 Phone 931-4468 <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN /7 RECONDITION <br /> _ /-37' DESTRUCTION /-7 <br /> PUMP INSTALLATION / /. PUMP REPAIR / 7tPUMP REPLACEMENT- 1 x7 a <br /> Other <br /> DISTANCE TO' NEAREST: SEPTIC TAMC Files SEWER LINES PIT PRIVY <br /> SEWAGEDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USES TYPE OF WELL CON15TRUCTION SPECIFICATIONS <br /> Indus'rtrial, M ""'� -�x Cable Toole ;Dia.'Iof Well Excavation <br /> Dome'sltic/private Drilled Dia. of Well Casing i <br /> Dommesitic/public• Driven Gauge of Casing . <br /> x Irrigation Gravel. Pack Depth of Grout Seal <br /> Cat kiolic Protection Rotary Type of Grout E <br /> Disposal Other Other Information ' Lean out sand <br /> Geophysical Surface Seal Installed 'B <br /> t <br /> PUMP INSTALLATION., Contractor <br /> Type of Pump H.P. k <br /> PUMP REPLACEMENT: /x/ State Work Done Replace original pump <br /> PUMP .REPAIR. ;. ; / / State Work Done <br /> PES-TRUCTION[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 /> informationiis true to the best -of my.knowl.edge and belief. I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO OUTING INAL INSPECTION. <br /> SIGNED y J<1' eyX <br /> TITLE Partner <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> DEPART)ENT USE ONLY <br /> PHASE I <br /> APPLICATION I ACCEPTED DATE ' <br /> ADDITIONAL COMMENTS: <br /> PRASE II GROUT INSPECTION r P =/FJRAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 07 <br />