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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7� <br /> _ _ THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7i� <br /> Application <br /> 1a*-f'i�� 'g� " (Complete In Triplicate) <br /> pplication is hereby /1Z/ <br /> 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 /> I <br /> JOB ADDRESS/LOCA TION 7 10 P P e E€ st ,She'?g E.a,ld , Saut h Hwy 26 CENSUS TRACT ;--9O—i3 <br /> Owner's Name Ch,rles ?foody <br /> Phone <br /> Address 800 4th 'St tat, Mo esto, Ca7,if. 9535 City <br /> Contractor's Name Purvbonc.e Drill 1.,ers, .0, r, 66,?1nd.ea,Cs+7.f. License # 2/4.a1C37a�..t <br /> Phone 93 ,1,68 <br /> 957367 <br /> TYPE OF WORK (Check) : NEW WELL /X-7 'DEEPEN / / _ .RECONDITION /r/ d"DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR''// PUMP REPLACEMENT ./7 <br /> Other / / -- <br /> DISTANCE TO NEAREST: SEPTIC TANK '!fJ0 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 f �' CONSTRUCTION SPECIFICATIONS <br /> Industrial { Cable To1 `` 'Dia. of Well Excavation 8" <br /> X Domestid c/private Drilled . -, `Dia. of Well Casing, " <br /> Domestic/public I Driven Gauge of- <br /> Casing L <br /> Irrigation 'Gravel Pa60 Depth of�Grout�Seal i 50 <br /> Cathodic Protection Rotary ' Type of Grout part ssrrci 9 art Ceinent <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B- : <br /> PUMP INSTALLATION: � �4 <br /> COntraCtor' , � �` <br /> Type of Pump - H.P. <br /> PUMP REPLACEMENT: / / State Work 'Done. <br /> PUMP .REPAIR: /_7 State fd6rk Done <br /> s ; <br /> � f <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> ,t k <br /> I hereby agree to-comply wit_h� all laws and regulations of the San Joaquin Local Health District <br /> and the State of California p taining to or regulating well 'construction. Within FIFTEEN DAYS <br /> after completion of my work on. aanew well.,�I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the wellland 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 4 <br /> PRIOR TO GROUTING AN FINAL I SPECTION."' <br /> SIGNED TITLE a <br /> DRAW PL T"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/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 , 376 2M <br />