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L 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. <br /> 3}o <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued?2- -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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joacuin Local Health District. <br /> JOB ADDRESS/LOCATION North side Hwy 2b & .28 Mile East Jaok Tone P�oad CENSUS TRACT <br /> vo- <br /> Owner's Name Albert Lind Phone <br /> Address 122 N. Orange, T�odi, Calif, 952 :0 , City _ -- <br /> Contractor's Name Furviance DriClers,F3ox 64,T.,inden Calif. 952-Xidense # 24.0J07 Phone ' 93i-/+468-, <br /> • i. <br /> TYPE OF WORK (Check) 'NEW WELL' /7 DEEPEN. `/ / RECONDITION^ / }DESTRUCTION <br /> -PUMP INSTALLATION / / PUMP REPAIR "/ / PUMP REPLACEMENT / <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 1.40 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD . CESSPOOL/SEEPAGE PIT OTHER <br /> _ PROPERTY LINE - PRIVATE:DOMESTIC WELL" _ PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ' <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> �X Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information .learn out & inst«Liner . <br /> Geophysical - Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor = <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /A""/ State Work Done PUTT and re-install- 30 HP Turbine <br /> PUMP .REPAIR: /�"S.tate Work Done° <br /> .� <br /> AES•TRUCTION_ 'OF_ WELL: Well Diameter Approximate Depth <br /> Describe-Material and Procedure <br /> I hereby agree to comply with.all1-laws and,regulations .of ,the, San Joaquin Local Health District <br /> and the State of California pertaining to or regulating we11 '"construction. Within FIFTEEN DAYS, <br /> after completion of my work on a new well, IEwill-furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify4the6 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 --G_&QVTIIgQ AM A FINAL ,INSPECT ION.._ :.; _ - _- - -_ _ <br /> SIGNE TITLE <br /> D W-- ' PLAN P'ON` RSE SID I <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS:` , <br /> PH&SE II GROUT INSPECTION /F AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E 1426 Rev. 1-74 <br /> V76 2�4 ` . <br />