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f <br /> + ` s `30muu FOCAL HEALTH DISTRICT A& <br /> FOFr:OFFICB USE. 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone; (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. "A$ Q) <br /> 10 7SW THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date Issued <br /> (Complete In Triplicate) X0'7 /ra&.-m 5111PApplictition is hereby made to the Scan Joaquin Local .19calth District for a permit to construct <br /> and/or install, the work herein described. <br /> County Ordinance No. 1862 and the Rules and This appllcatinn is made in compliance with San Joaquin <br /> Regulations of the San 'Joaquin Vocal Health District. <br /> JOB ADDRESS/LOCATION Mile a East HeEn Road & 3/4 Mile North Did" Road CENSUS TRACT <br /> Owner's Name Dr. Kistler Ranch <br /> Phone �— <br /> Address <br /> City <br /> i Contractor's Name Purviance Dri]-leas p.o.Box 64,Tinden, C ifY.icease ¢ p4�t 7 Phone '937-44b8 <br /> TYPE OF WORK (Check): NEW WELL 'I7 DEEPEN JRECONDITION _ DESTRUCTION f tQ <br /> PUMP INSTALLATION / PUMP REPAIR' -7 PUMP R$PLACEMENT I? 1 <br /> Other j� o <br /> DISTANCE TO NEAREST: SEPTIC TAMC S$WER LINES PTT PRIVY ; h <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT'"" OTEiER <br /> I, <br /> PROPERTY LINE PRIVATE DOMSSTIC WELL:' ' ,- PiMLIC DOMESTIC WE L <br /> INTENDED USE TYPE'OF WELL CONSTRUCTION'SPECI�'ICATIONS <br /> Industriaji' /p x Cable Tool. Dl�- of Well Excavation i <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 <br /> Geophysical "'"""- — Other Information' lean 4 and & anar <br /> SurfaceSe 1 Insta led B i ,'casln <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> FUMt' REPLACEMENT: State Work Done <br /> -State.Work--Done <br /> ES'TRUCTIT OF WELL: Well Diameter f <br /> Describe Material and Procedure Approximate Depth <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 we <br /> after Within FIFTEEN DAYS <br /> after comp 3•e tion of my work an a new well, 1 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-beat of n►y knowledge and belief. i WILL CALL FOR A GROUT INSPECTION <br /> 'RIDR 1v G-WUTING A f NAL INSPECTION. <br /> M 5IGN� ED <br /> TITLE Partner <br /> W PLOT PLAN ON R731TSRSB SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY _ <br /> 1 4FP IL CATION' ACCEPTED By <br /> YTIONAL COMMENTS: DATE . <br /> PHASE II GROUT INSPECTION <br /> INSPECTION 8Y _ DATE PHASE III FINAL INSPEEFI-0N <br /> .�.. INSPECTION BY <br /> DATE <br /> E H 1426 Rear. 1-74 f- .. . ' <br /> f.17� +aar <br /> I <br /> i <br />