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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephoner (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION -OR PUMP PERMIT Permit No. ?,?-,-37 <br /> . 3 <br /> THIS PERMIT EXPIRES l YEAR FROM-DATE_ ISSUED Date Issued 3 7 <br /> (Complete In Triplicate) -0,?/-_3c(c-2_0 ! <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;arid"the Rules and Regulations of the San Joaquin Local 'Health District. <br /> JOB ADDRESS/LOCATION 125' E68t rine Road and 160' Uorth Iaiormon Slough EES S�T�RA�CT , <br /> Owner's Name . J. 113;.:Firpo Phone <br /> Address. P. 0. `ox 164 I T,S,nden, Calif. 95236 City <br /> Y~ <br /> Contractor's Name- Purvianc.e_:Pril1.ers,P.0.Box 61�,Tindern, C � if.License �� 0?07 Phone 93 "•4468 <br /> TYPE OF WORK (Check) : NEW WELL /x/ _DEEPEN /= /y RECONDITION / / � DESTF-R IONr- <br /> PUMP INSTALLATION /a�/ PUMP REPAIR / / PUMP REPLACEMENT /? <br /> -Other-/ / . <br /> DISTANCE TO NEAREST: SEPTIC-.TANK 200' SEWER LINES 200 PIT PRIVY \! <br /> w SEWAGE .DISPOSAL FIELD 200' CESSPOOL/SEEPAGE PIT OTHER, <br /> PROPERTY LINE.- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL . CONSTRUCTION SPECIFICATIONS • <br /> Industrial_:.. -. � x Cable Tool Dia. ..of Well Excavation IT5 - !y � _S_ !1I <br /> Domestic/private. Drilled Dia. of Well Casing - loll <br /> Doiriestic%public Driven Gauge of Casing 10 <br /> 4 Irrigation i Gravel Pack Depth of Grout Seal 50' — ia - <br /> Cathodic Protection Rotary Type of Grout . Leet Cir}1en.t. with Conductor pips <br /> Disposal Other Other Information " I <br /> GeophysicalhE"j Surface Seal Installed By: <br /> r � E <br /> li <br /> PUMP INSTALLATION: ContractorFurviah Dri jets`, <br /> Type of Pump—y.resaure Turbinz H.P. Unknown at <br /> PUMP REPLACEMENT: , f / State Work Done <br /> 'PUMP'�-REPAI-R. - ,-`/-�/­�iState-Work-Done <br /> DES,TRUCTI OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure j <br /> I hereby agree to comply with .ail laws and regulations of the�San Joaquin .L6cal 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 iiew,well., I will furnish the San: baquin Local Health District a <br /> WELL DRILLERS REPORT ,of 'the well-"and n6tify'.them before putting.the-we'll 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 GROUTING A'.FINAL '-INSPECTION. <br /> SIGNED TITLE, Owner. <br /> D'IiAW:Pi, T PLAN ON RE'V'ERSE SIDE) <br /> 4 # FOR D PARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ` .X -DATE <br /> COMMENTS: <br /> PHASE II GROUT INSPECTION- <br /> SPECT <br /> NSPECTION P E I AL INSPECTIO <br /> SPECT N BY DATE INSPE TIO ATE <br /> s _ . . p„ p <br /> 426 Rev. 1 74 <br />