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SAN JOAQUIN LOCAL HEALTH DISTRICT GITf L <br /> FOS OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ! r <br /> Telephone: (209) 466-6781 <br /> At APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 <br /> r <br /> THIS PERMIT EXPIRES I YEAR FROM DATE -ISSUED Date Issued /6'2`/ <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 /> a 54314 -66,F,eHa <br /> 30B ADDRESS/LOCATION Wa, <br /> ,tgida Begglaer 1 <br /> 3d/No of Hw 26 smile CENSUS TRACT <br /> k Owner's NameGenrZp, ori <br /> Phone ' <br /> F AddressBeecher Rd. Stockton Ca 5205 city - Stockton <br /> Contractor's Name Purvi nce Driller-s-, POB 64, Linden License # 240107 Phone 931-4 .68 � <br /> TYPE OF WORK (Check) : NEW WELL/V DEEPEN - _ RECONDITIONDESTRUCTION f7 <br /> ► PUMP INSTALLATION / / PUMP REPAIR/_7PUMP REPLACEMENT /7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK 1()o SEWER LINES PIT.PRIVY �lr <br /> SEWAGE DISPOSAL FIELD 8fit-] CESSPOOL/SEEPAGE PIT OTHER <br /> - PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECI Cl' ' NS <br /> Industrial _X_ Cable Tool Dia. of Well Excavation <br /> Y Domestic/,private Drilled Dia, of Well Casing $+1 <br /> Domestic/public Driven Gauge of Casing 12 <br /> Irrigation ViiGravel Pick Depth of Grout Seal ��Qt <br /> Cathodic Protection Rotary <br /> - Type of Grout neat cement <br /> I Disposal � Other Other Information <br /> Geophysical Surface Seal Installed B <br /> --..-- <br /> PUMP INSTALLATION: Contracto`r� <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: .. /,State'e Work Done <br /> PUMP '.REPAIR:':. / ,�#State -Work Done -- <br /> DESTRUCTION OF WELL: Well Diameter Approximate DepthYf� + <br /> ` Describe Material and Procedure <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 isto the-best-of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTtr D A. I'INAL INSPECTION. k <br /> SIGNED <br /> � TITLE Partner <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY p <br /> PHASE I lA' ____ ` -7)7 7 <br /> APPLICATION ACCEPTED BY - DATE,_ .() .. # <br /> ADDITIONAL CQMME;NTS: <br /> Pa II AROUT INSPECTION P X AL INSPECTI <br /> INSPECTION BY ✓ DATE A -7-7 V INSPECTION BY DATE $� <br /> E H 1426 Rev. 1-74 r r,/7 E� 9M <br />