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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> r-' • ' <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,�tJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued S <br /> (Complete In Triplicate) <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 /> 1 ,800'E. of 99 East Frontage Road, Mosher Manor, Tract No. 1.030 <br /> JOB ADDRESS/LOCATION Subdivision of San Joaquin Count CENSUS TRAC? <br /> Owner's Name Ei-Centennial Builders Phone <br /> Address 161.2 17. Mora Ave Stockton Wiff. 95207 City <br /> Contractor's Name Purviance Drill ers,P.O.Box 64 j,inden,Cal if. License # 240"1.07 Phone 931.-1+1+68 <br /> i <br /> TYPE OF WORK (Check) : NEW WELL J / DEEPEN / / RECONDITION /77 DESTRUCTION /X7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /? <br /> AL <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL - PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> 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: j_/ State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 12" Approximate Depth 2250' <br /> Describe Material and Procedure _(Phoned in for this information) <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 GROUTING AN FINAL JNSPECTION. <br /> TITLE Partner <br /> SIGNED <br /> (DRAW PD PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/ NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ;;� <br /> 3%76( ' `' <br /> E H 1426 Rev. 1-74 <br />