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M r SAN JOAQUIN LOCAL HEALTH DISTRICT -- -- <br /> FOR;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> c� r Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 'YEAR FROM DATE ISSUED Date Issued --- /P '7d <br /> (Complete In Triplicate) <br /> Application is hereby made to the Sae, Joaquin Local :Health District for a permit to construct I <br /> and/or install the work herein described. This application is made in compliance with San.Joaquin <br /> County Ordinance <br /> �Noo71862 and the Rules and Regulations of 'the San Joaquin Local Health District. <br /> JO ADDRESS/LJC�,TTON1 50, north of Hiway 12 <br /> -_. QQ West of Tecllinb,u2e_ CENSUS TRACT <br /> Owner's Name Hi1ja,2a_Kgol _._. -' Phone <br /> Address 18096 N Cherry Rd. City, icor Ca 95240 <br /> Contractor's Name _ Purviance Dri lens _ ' License #2401.07 Phone $$ <br /> TYPE OF WORK (Check): NEW WELL/W DEEPEN -/7 RECONDITION /7 DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR /7 PUMP REPLACEMENT /7 <br /> Other /% i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES1,�; l PIT PRIVY � . <br /> SEWAGE DISPOSAL FIELD 2 501 CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL A,y' ! CONSTRUCTION SPECIFICATIONS <br /> Industrial . _�— Cable Tool Di :rof Well Excavation <br /> Domestic/private Drilled Dia 'of Well Casing <br /> Domestic/public Driven Ga^ of Casing gage <br /> X jrrigttion Gravel Pack DojiN of Grout Seal <br /> 'c Cathodic Protection Rotary Typ�r,of Grout ' ' l <br /> Disposal Other Other Information '': r <br /> Geophysical Suif ace_Seal_ Installed By: -_ l <br /> PUMP INSTALLATION: Contractor <br /> --�----Typ of Pump f �... H.P. <br /> 1 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP '.REPAIR: /_7 State Work Done <br /> 4P <br /> PES 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 /> G and the State of California pertaining to or regulat.iig well 'construction. Within FIFTEEN DAYS <br /> r 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 /> k information is true to the best of my knowledge- and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING INAL INSPECTION. <br />' SIGNED IV.44 06 i TITLE tiJA <br /> 4 (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY -� <br /> PHASE I <br /> APPLICATION ACCEPTED BY t DATE 7� <br /> ADDITIONALLCOMMENTS: 9 r <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> t <br /> ' E'H 1426 . Rev. 1-74 -- ," �1-74 2M <br />