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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FO>w,OPFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 (7 W <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � �.. <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued -L�- 7 ` <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 Joaquini <br /> County Ordinance No. 1862 and the Rules and F&giklations of the San Joaquin' Loca1 Health District. ' <br /> �-� - •cJL Intersection <br /> JOB ADDRESS/LOCATION �OE Yds0 eo u <br /> gh Hwy 12 & 1_ Iii. East of 4y 88 & 22 CENSUS TRACT <br /> r <br /> Owner's Name George-A. ,Kant-z, Phone <br /> Address 22000 H 12� C1-ement s CQ if. City <br /> Contractor's Name Ross Purvi.ance P.O.Box 1-85 ?�indeh Calif. License # 180532 Phone 887-3480 <br /> 95236 { <br /> TYPE OF WORK (Check) :-, NEW_WELL_ -DEEPEN ,/ 7RECONDITION-"/_'/,,DESTRUCTION- / -¢-T. <br /> "PUMP 'INSTALIXTION- 7VPUNIP-REPA�R :/ /—PUMP REPLACEMENT <br /> Other J-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK 3001 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 300' 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 4 Dia. of Well Excavation � IN <br /> Domestic private._- - -- Dril]ed-_w� =- TDia::a£`Well rCas3nE�'"'" <br /> Domestic/public Driven, Gauge,ofCasing I 10 <br /> Irrigation Gr&vel Pack Depth of Grout Seal 72' <br /> Cathodic Protection Rotary Type of Grout Neet. Cement <br /> Disposal Other _. Other Information 12", Conductor &.Jacket <br /> Geophysical r "Surface Seal Installed By: ' <br /> PUMP INSTALLATION: ; Contractor� Ross Purviance, <br /> Type of,"Pump Submersible H.P. 15 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done -- -- - - -F <br /> DES-TRUCTION OF WELL: Well Diameter Approximate Depth -_ <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 /> t 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 /> f informatio s triA to the best of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO AOJ?TINQ1AhD A FINAL INSPECTION. <br />' SIGNEDTITLE <br /> (DEW PL T PLAN ON RE ERSE SIDE-) tj .!! <br /> : <br /> 4 FOR DEPARTMENT USE ONLY <br /> PHASE I Z <br /> DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br />` PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> a <br /> INSPECTION BY DATE INSPECTION BY �./._J -__ DATE 41_-7. V _ <br /> • 3/76 2M <br /> E H 1426 Rev. 1-74 �. - <br />