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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR,OFFICE USE: .1601 E. Hazelton Ave. , Stockton, Calif. <br /> ° Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRICTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issue '��. <br /> d •� <br /> (Complete In Triplicate) Of- <br /> Application is hereby made to the Sart Joaquin Local Health District for a permit to construct � <br /> d <br /> and/or install the work herein described. This application is made in compliance with San Joauin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health Distriq <br /> ct. <br /> k27ISI.3 ". 5�8Imile North of Frazier Rd. <br /> JOB ADDRESS/LOCATION 1j Mile Ea.tt of Olements, Rd. CENSUS TRACT <br /> Owner's Name Hillside Orchards -4 <br /> Phone <br /> Address 22261 E. Linden Orchards Rd. City Linden Ca <br /> Contractor's Name Purviance Drillersk ~ i <br /> --- $ License # 24�0�107 Phone g87-355 <br /> TYPE OF WORK (Check); NEW WELL -/X-7 DEEPEN/7 RECONDITION /-7 DESTRUCTION /'j <br /> PUMP INSTALLATION /% PUMP REPAIR / / PUMP REPLACEMENT /� w <br /> Other / / [� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESf PIT PRIVY '�f! <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER y <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL ^' [ <br /> INTENDED USE TYPE OF WELL_ �' CONSTRUCTION SPECIFICATIONS L_} <br /> Industrial t XX Cable Tool ;Dia. of Well Excavation 1411E <br /> ^'Domestic/private a Drilled Dia. of Well Casing <br /> Domestic/public Driven ",Gauge of Casing e <br /> _ Irrigation `� Gravel Pack Depth of Grout Seal s 1 <br /> Cathodic Protection Rotary Tgrpe of Grout <br /> Disposal Other ,,x :'1 'rPiher Information <br /> Geophysical - <br /> `Surfaoe Seal Installed B <br /> PUMP INSTALLATION Contractor <br /> Type of Pu6p �. H.P. <br /> _ <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP MPAIR: /7 State Work Done <br /> ES1RUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> i <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 worm on a new well, I will furnish the-'- San Joaquin Local Health District a t <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 I <br /> PRIOR TO GROUTING D FINAL INSPECTION. <br /> SIGNED <br /> TITLE • <br /> -* (DRAWPLOT PLAN ON REVERSE SIDE ' <br /> PHASE I F R EPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY �i DATE I6 7d• <br /> ADDITIONAL COMMENTS: 7 <br /> PHASE II GROUT NS ECTION PHASE III FINAL INSPECTI N <br /> INSPECTION BY DATE <br /> INSPECTION BY DATE I! <br /> E H 1426 Rev. 1-74 # <br />