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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR.'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES YEAR FROM DATE ISSUED Date Issued 41 <br /> Application is hereby made to the San (Complete <br /> LacalHealth Triplicate)District for a <br /> 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 /> JOB ADDRESS/LOCATION __1,7001 S. Hwy 26 & 1 mile E. Jack Tone Road <br /> CENSUS TRACT <br /> Owner's Name Frank Giannecchini Phone ' <br /> Address 25400 E. Hwy 26, Linden, Calif. <br /> City " <br /> Contractor's Name Purviance Drillers, pox 64, Linden, Cal-:if. License # 24UI07 Phone 937.-44-68 <br /> TYPE OF WORK (Check) : NEW WELL /7 DEEPEN L/�-7 RECONDITION Ix� DESTRUCTION f j <br /> PUMP INSTALLATION / / PUMP REPAIR /7 PUMP REPLACEMENT /-W <br /> Other /_7 <br /> —.- <br /> DISTANCE TO NEAREST: SEPTIC TANK 95' SEWER LINES 901 •`PIT. PRIVY, :7 <br /> t <br /> SEWAGE DISPOSAL FIELD _ CESSPOOL/SEEPAGE�PIT `:\ OTHER <br /> - ----'-•--PROPER-T-Y LINE-- PRIVATE `DOMESTit WELL'.-' -- -PUBLIC-DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL ,- CONSTRUCTION SPECIFICATIONS .- _`_7-- <br /> Industrial xI Cable <br /> PECIFICATIONSIndustrialxCable Tool Dia. of Well Excavation Existing8" dell <br /> a Domestic/private Drilled " Dia. of Well Casing 6-5/81, x 0 a col_umn <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Pr-otection -�� RotaryType of`Grout <br /> .Disposal - Other I <br /> ..._� _, Other Information ' ' <br /> ' <br /> Geophysical Surface Seal Installed B <br /> 3 . <br /> PUMP INSTALLATION: ,�,.>. Contractor s <br /> Type.o£..Pum�p H.P. . <br />'UMP REPLACEMENT: tate Work Done", Re-install 3 hl' Turbine - <br />?UMP ,REPAIR: / / State Work Done- <br /> LE-SO_UCT10N OF WELL: Well Diameter Q , <br /> Describe Material and- Procedure Approximate Depth V� <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> end the State of California pertaining to or regulating well ''construction. Within FIFTEEN DAYS <br /> rfter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> TELL DRILLERS REPORT of the well and notify them before putting.the..well. in.use... .The above <br />.nformation is true to the-best-of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> RIOR TO GROUT G A FINAL INSPECTION. <br /> IGNED t <br /> TITLE <br /> PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> RASE I ` <br /> PPLICA 9N' ACCEPTED BY DATE ' <br /> DDITIONAL COMMENTS: <br /> PHASE Ii.G N E ION P AL INSPECTION <br /> NSPECTION BY DATE INSPECTION DATE <br /> 77 U4 <br /> r <br /> E H 142.6 Rev. 1-74 i' 11/7K 9M <br />