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f <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0R7UF_FICE USE: 9 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ®9ly° <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /1-g-7� <br /> (Complete In Triplicate) <br /> Application is Hereby made to the San Joaquin Local Health District for a permit to construct <br /> rind/or install the work herein described. This application is made in compliance with San Joaquin. <br /> County Ordinance No. 1862 and the Rules .and Regulation of the San Joaquin Local Health District. <br /> .TOB ADDRESS/LOCATION South side Baker Road, Mile East Tully'-Road CENSUS TRACT <br /> Owner's Name T,eo Arrigone Phone <br /> a � 1 <br /> Address 1:5830 E. Baker Road, Linden, Cal-if. 95236 City ' <br /> -Contractor's NameFurviance Drill ers,Fox 64,T,inden,Calif.95236 License # 240-T07 <br /> Phone 931.4468 <br /> TYPE OF WORK (Check): NEW WELL/_7 DEEPEN -/7 RECONDITION /7 DESTRUCTION f7 <br /> PUMP INSTALLATION/ / .. PUMP REPAIR'/W PUMP REPLACEMENT /x7 <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 SPECIPICATIONSi <br /> Industrial Cable Tool ,, Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing w <br /> x Irrigation Gravel Pack Depth of Grout-Seal <br /> Cathodic Protection Rotary Type of Grout - M, <br /> _.. <br /> i _Disposal-_, __-Other ` Gther-Information <br /> Geophysical Surface Seal Installed By <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump , H.P. <br />{ " Repair and re original ,. €` <br />� PUMP REPLACEMENT. _X/ State Work Done I Paz ?ace• P- g ISP � <br /> PUMP REPAIR: ✓ /, State Work Done <br />{ _ <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br />' �� Describe Material and Procedure <br /> 4 <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> 4,t. <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 /> informati true est of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR GROU IN F' NSPECTiON. <br /> SIGNED" TITLE Partner <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> { DEPARTN T USE ONLY <br /> f PHAS E I / <br /> I APPLICATION ACCEP „ DATE' <br /> l/6 / <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I INAL INSPECTION <br /> ` INSPECTION BY DATE INSPECTION BY DATE ., �7 <br /> W <br /> "r F H 7LL26 upt.- 1-74 /rpt 1.41 - +� ����o � - !117 � <br />