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n <br /> §MJ JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFi.OFFICE USE: .6C� F. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> ' L APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7ti-_io Q5-p <br /> THIS PERMIT EXPIRES I YEAR FROM BATE ISSUED Date Issued <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 Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION East side Clements Road, North side Dead-end Brandt, CENSUS TRACT ' <br /> Owner's Name Darwin tewis Phare <br /> Address 23779 E. Frandt Road, T.odi, Calif. .95240 <br /> City. <br /> Contractor's Name Purviance Drill.ers,Eox 64,T,inden,Cal if.95236License # 240-107 Phone 931-41,6$ . <br /> TYPE OF WORK (Check) : NEW WELL /% DEEPEN / RECONDITION DESTRUCTION /7 <br /> PUMP INSTALLATION /% PUMP REPAIR/� PUMP REPLACEMENT /-7 <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD - CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DC}MESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELT, CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation , �V ! <br /> G <br /> Domestic/private _ Drilled Dia. of Well Casing <br /> + t Domestic/public Driven Gauge of Casing <br /> x Irrigation . Gravel Pack Depth of Grout Seal <br /> Cathodid� Protection Rotary Type� yp. of Grout <br /> Disposal Other Other Information <br /> -Geophysical - � Surface Seal Installed B : 1 <br /> Il i <br /> PUMP INSTALLATION: Contractor <br /> _ Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: /g/ State Work Done Repair and replace original pump I <br /> . i <br /> PUMP ,REPAIR: 17 State Work Done . . . <br /> r7 DES;TRUCTION OF WELL: Well Diameter <br /> Describe Material. and Procedure Approximate Depth <br /> r., 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 /> 2 after completion of my work on a new well, I will furnish the San Joaquin Local Health District a j <br /> WELL DRILLERS REPORT the well and notify them before putting..the. well in.use.. The above <br /> ?- ' informa on s tr he. est of-my-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR GR TI <br /> '._• E AL INSPECTION. <br /> SIGNED si <br /> TITLE Partner <br /> (DRAW PLOT PLAN ON REVERSE SIDE) I <br /> R DEP TMENT USE ONLY <br /> PHASE I / <br /> APPLICATION OC - DATE <br /> ADDITIONAL COMMENTS: I <br /> 'j PHASE II GROUT INSPECTION <br /> INSPECTION BY DATE PHAS I FIN INSPECTION <br /> INSPECTION BY DATE <br /> E H 1426 Rev.-,.1-74 <br /> it/75 tri <br />