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SAN JOAQUIN LOCAL ktALTH. DISTRICT <br /> -TO-F--,OFFICE USE: 1601 E. Hazelton Ave. , Stockton", Calif. <br /> Telephone: (269) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. f7, <br /> THIS PERMITEXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> 20: N 'Sf �'E•c �(,�' ,(Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to constrict <br /> and/or install the work herein described. This application is made in compliance with' .San Joaquiin <br /> County Ordinance Foo: 1862 and the Rulers and Regulations of the San Joaquin Local Health District. ; <br /> ,JOB ADDRESS/LOCATim 7 10 .1ffil-e East Shelly Road , South Hwy 26 CENSUS TRACT 047- 210-1-3 s' <br /> ^Owner's Name C harl..e s IVioody Phone <br /> rr <br /> Address 800 14th Street ModestoCalif. 9535G ` City <br /> 114 <br /> Contractor's Name Purdyante Drillers, '.O.Box6,4,Ilindeti;Calif. License 4� 240 07 Phone 931:-4468 <br /> LiL,6S ' <br /> TYPE OF WORK heck): NEWy WELL AL/g/ . DEEPEN- /_%- RECONDITION_/—_/�DESTRUCTION /_ <br /> PUMP INS TLATION / / PUMP REPAIR- / %--PUMP .REPLACEMENT /7 <br /> Other / / <br /> F <br /> DISTANCE TO NEAREST: SEPTIC TANK .1001 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 1001 CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL . CONSTRUCTION SPECIFICATIONS <br /> Industrial x Cable Tool , r -.Dia of Welll-rExcavation Aw , <br /> -- x Domestic/private Drilled Dia.' .of Well Casing a �] M <br /> Domestic/public Driven Gauge ofCasing 10 <br /> 1 <br /> Irrigation -Gravel Pack- - Depth of---Grout Seal 50 <br /> Cathodic Protection. Rotary` Type of Grout 2 part gand7 J part Cement ' <br /> Disposal Other Other Information- <br /> Geophysical Surface Seal Installed B <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 Deptt <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 is true to the best of my-knowledge and belief.. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING D FINAL I SPECTION.�,1 <br /> SIGNED ' <!: '` 'e TITLE <br /> DRAW PI: T' PLAN ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> - F <br /> APPLICATION ACCEPTED BY DATE r <br /> ADDITIONAL COMMETS: f <br /> PIW§E GROUT INSPECTION PHASE /F AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY - DATE a } <br /> E H 1426 Rev. 1-74- ms ��3/76 2M <br />