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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOPi,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209), 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �- 41g /llJ ' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /f 2-21- <br /> t (Complete In Triplicate) pg/- 200-3( <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 Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION North side ofigi— wa' 26 'a rox. 1,000! east of CENSUS TRACT <br /> Duncan Road, <br /> Owner's Name Linden County Water District t Phone 8$7-3416 <br /> Address" _-_F;0= Box 595 CityLinden, California + <br /> 95236 <br /> Contractor's Name Unknown License # Phone <br /> TYPE OF WORK (Check): NEW WELL LV DEEPEN /? RECONDITION- /7 DESTRUCTION /7 <br /> PUMP INSTALLATION /% PUMP REPAIR /7 PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 300' `= SEWER LINES {100' PIT PRIVY- <br /> SEWAGE DISPOSAL FIELD 300' CESSPOOL/SEEPAGE PIT OTHER -N <br /> PROPERTY LINE 23 PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL w <br /> INTENDED USE TYPE -OF WELL CONSTRUCTION SPECIFICATIONS <br /> m ' <br /> Industrial Cable Tool Dia. of Well Excavation <br /> '> Domestic/private _ X Drilled Dia., of Well Casing 14 inches <br /> X Domestic/public Driven Gauge of Casing 10 <br /> Irrigation Gravel Pack Depth of Grout Seal 50' (min.).. <br /> Cathodic Protection Rotary Type of Grout Cement. <br /> Disposal Other Other Information <br /> Geophysical Surface_Seal Installed By: i <br /> PUMP INSTALLATION: Contractor Unknown <br /> Type of PumpDeep Well- Turbine _�_ H.P. 100 <br /> PUMP REPLACEMENT: / / State Work Done <br /> •PUAU' .REPAIR: /7 State Work Done <br /> jRES;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 /> 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 /> information is true to the-best-of- my-knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO MUTING .AND, A FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> VV FOR DEPARTMENT USF ONLY <br /> PHASE I }j <br /> APPLICATION ACCEPTED BY DATE l+ <br /> ADDITIONAL_ COMMENTS: <br /> P E I GROUT INSPECTIO PHAU,III4EINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE 7� <br /> 4 E .H 1426 Rev. 1-74 1-74 2M <br />