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rrv� 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. 7 7-�_371J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date' Issued � 0 7 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct i <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 /> 3e--03 <br /> JOB ADDRESS/LOCATION 2 i. West Castle Rd. Ali. South French Cam Rd.CENSUS TRACT` + <br /> lo <br /> Owner's Name Tsa c Arditi Phone <br /> Address 60 East 42nd Street New York N.Y, 10077 City y <br /> Contractor's Name Purviance Dri1-l.ers,P.O.Box 64,Linden,Cal if. License # 240107 Phone ' 931-U,+68 <br /> 95236 J <br /> TYPE'OF WORK (Check) : NEW WELL *� .,DEEPEN—/7F/R ONDITION /_� DESTRUCTION <br /> PUMP INSTALLATION] / PUMP REPAIR/ / PUMP REPLACEMENT /7 1 <br /> Other. /~/ t <br /> DISTANCE TO NEAREST,:. SEPTIC TANK Mi, SEWER LINES PIT PRIVY <br /> _ -- SEWAGE DISPOSAL FIELD j Mi. CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> w ' INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial x Cable Tool Dia. of Well Excavation 14" 5Fr <br /> Domestic/private Drilled Dia. of Well Casing 1-4" <br /> Domestic/public Driven Gauge of Casing 3/1611 Plate ' <br /> X Irrigation Gravel Pack Depth of Grout Seal 50' <br /> Cathodic Protection r Rotary Type of Grout Neet Cement <br /> Disposal Other Other In 20" Conductor & Jacket <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done - - -- - ; <br /> PUMP.REPAIR:... / /-,.:state-Work Done <br /> DESTRUCTION_ OF WELL: Well Diameter _ Approximate Depth <br /> Describe. Material and Procedure , <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 we11 '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 GROUTING A FINAL INSPECTION. <br /> SIGNED TITLE Partner <br /> DRAW PLOT, PLAN 'ON RE RSE SIDE) ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I I <br /> APPLICATION ACCEPTED BY `' - �„ DATE -� -7� <br /> ADDITIONAL COMMENTS: <br /> PHASE I GRO T INSPECTION }" PHASE I I/FINAL INSPECTION <br /> INSPECTION BY DATE <br /> -7 -7 - .jNSPECTION BY DATE -7 -7'7 { <br /> E H 1426 Rev. 1-74 �-�" ti /�^� •/ moo/ Xv- 11WI --- 761 <br />