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f / SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: VV 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERUIIT Permit No. 7 Z y <br />'d THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7/ <br /> u , <br /> t (Complete Iii Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> i 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 /> JOB ADDRESS/LOCATION Mile East of 99 Htr & 700 YF3 h pe�f CENSUS TRACT 065- f k7 37; <br /> Owners Name Mrs Fred San uin6tt Phone ' _ <br /> Address <br /> 4880 E Pa tie RoAd City _ <br /> Contractor's Name Purviance Drillers License # 2 0 0 Phone <br /> 931=&468 <br /> S' <br /> PUMP INSTALLATION ' _w` <br /> TYPE OF WORK.w{Check}: NEW:OL1 /� DEEPEN-/ �RECONDITI4N,.f Y�DESTR_UCTION /?_ <br /> _ / PUMP REPAIR / PUMP REPLACEMENT 7� - " ^��■ <br /> Other -/ / <br /> 4 <br /> DISTANCE TO NEAREST: SEPTIC TANK 2501 SEWER LINES PIT PRIVY � =.Q <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial X Cable Tool Dia, of Well Excavation 120 ` <br /> Domestic/private _ Drilled Dia. of Well Casing 2n <br /> Domestic/public Driven Gauge of Casing 10 <br /> _ a Irrigation ,-'{'� Gravel <br /> Pack Depth of Grout Seal <br /> Other Rotary Rotary <br /> Type of Grout <br /> Other Other Information A xoX2601 D e <br /> iD <br /> PUMP INSTALLATION: Contractor Furviance Drillers <br /> Type of Pump E3d H.P. <br /> PUMP REPLACEMENT: /x/ State Work Done Install Customer Pum in 1QeR 12" -We I <br /> T PUMP REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL. Well Diameter Approximat — epth <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 FIF'T'EEN DAYS r <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. <br /> SIGNED. - .TITLE `Partner <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> � _ . <br /> APPLICATION ACCEPTED BY r DATE 6-<o A -9 <br /> ADDITIONAL COMMENTS: i A <br /> PHASE II GROUT INSPECTION PHASE II/FINAL INSPECTION <br /> `INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION-PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 2426,.: . <br /> 4/72 1M <br />