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9 Y 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. 77 110, <br /> 4 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued )-7 7 <br /> (Complete In Triplicate) r <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 250' South Fairchild & 475' East Burge Road CENSUS TRACT <br /> Owner's Name Ron T,onge Phone <br /> Address ak 227_ Paragon Avenue, Stockton, Calif., 95207 City <br /> Contractor';s Name Purviange Dril.l.ers,Box 64jinden,Cal.if.9523 ,icense # 240-107 Phone ' 931-4468 <br /> If <br /> i <br /> TYPE-Ole-WORK-(Check): _NEW WELL-:./_ /_DEEPEN._/,7/� RECONDITION / 7,,,DES- <br /> TRUCTION_ �f <br /> _._...PUMP INSTALLATION / ./ PUMP REPAIR / / "PUMP .REPLACEMENT. /T <br /> t <br /> DISTANCE TO NEAREST: SEPTIC TANK 501 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> V PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL ICONSTRUCTION SPECIFICATIONS <br /> Industrial _�L, ..Cable Tool Dia; "of-Well Excavation <br /> Domestic/private Drilled- . - N-110Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing j <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 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /a/ State Work Done Pull) reboyn & reinstall. 7.5 HP Turbine <br /> PUMP .REPAIg: / / 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 GiOUTiNV, A FINAL INSPECTION. <br /> SIGNED I TITLE Partner <br /> DRAW Ph T PLAN 'ON RE ERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 1G <br /> APPLICATION ACCEPTED BY z, DATE <br /> ADDITIONAL: COMMENTS:. , <br /> PHASE II GROUT INSPECTION /F AL INSPECTION <br /> INSPECTIONIBY DATE INSPECTION BY DATE (� <br /> � r <br /> E H 1426 Rev. 1-74 3/76 2M i <br />