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f <br /> SAN JOAQUIN LOCAL HEALTH:DISTRICT r , <br /> F0 0: CE„US 1601 E. Hazelton Ave: ;' Stbckton, Calif. <br /> ' Telephone; • '(209). 466-6781 • GG <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS; PERMIT -EXPIRES 1 YEAR FROM,DATE ISSUED Date-Issued <br /> (Complete In-Tripiicate) <br /> Application 'is hereby made to.:,-- he 'San Joaquin Local Health District for a permit to construct <br /> and/or install the work. heredescribed. This. application is.made' in covipliance with San Joaquinl <br /> County Ordinance-`No. 1862 andFlthe Rues and Reg ul t. ions of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION; 1/9 Mile <br /> orth Hildreth & 1 M17,e•East 99 .Front age CENSUS-TRACT ' <br /> Owner's-Natue! Doug Edge Phone <br /> Address 53,.7 Hildretq TAne Stockton, Calif.`95212 City <br /> Contractor's Name Ross Purvis ce D.rillAng P.O.Box 185 tinden License # M532 Phone' 887-3480 <br /> - al. 95236 <br /> TYPE OF WORK (Check): NEW WELL"`/[ DEEPEN '/-7 RECONDITION /�., DESTRUCTION /_7 <br /> PUMPAL <br /> INSTALLATION /x/ PUMP REPAIR/-7—PUMP REPLACEMENT f7 <br /> Other /. J <br /> DISTANCE T0- NEAREST: ''SEPTIC TANK 2001 SEWER LINES PIT PRIVY r <br /> SEWAGE DISPOSAL FIELD 2001 CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY. LINE -- PRIVATE DOMESTIC WELL'—�.* PUBLIC DOMESTIC WELL—T— <br /> INTENDED USE TYPE OF WELL • CONSTRUCTION SPECIFICATIONS <br /> ' <br /> Industrial • f x Cable Tool, Dia, of Well Excavation <br /> x- Domestic/private i Drilled Dia.' of Well .Casingell <br /> , <br /> Domestic/public 5 Driven Gauge of Casing I ' •� <br /> IrrigationGravel Pack-- <br /> 'i�pept}r of Grout Seal 50= ^A. <br /> Cathodic Protection i Rotary :v. r Type of- Grout Neet Cement - p ex mix. <br /> Disposal Oth-gr,-- .._ _ 1 ` '-Othei 'Information, ' <br /> Geophysical �/ Surface_Seal. Installed By: <br /> PUMP INSTALLATION: Contractor Ross -Purviance Dril.'1ixg . } <br /> Type hof, Pump 5tfff9ible `�' �..�• _ .. . <br /> PIMP REPLACEMENT: / / State Work Done <br /> Pf]MP ,REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Wei <br /> 1' Diameter <br /> . Approximate Depth <br /> Describe Material- and Procedure - - <br /> I hereby agree to comply i with_ all laws and regulaftons' of 'the San •Joaquin Local Health District 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.,we,lil and notify them before putting the.-well in use. The above <br /> { information a. tru t the-;best" of- my_knowledge and belief, I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO V ING D/A FINAL.,INSPECTION. <br /> SIGNED ' TITLE Owner <br /> (DRAW P PLAN'ON RE E SE SIDE i; <br /> FOR DEPARTMENT -USE ONLY <br /> PHASE I �{ n <br /> APPLICATION ACCEPTED. BY C•! 1 DATE <br /> '1,6 A ; <br /> ADDITIONAL COMMENTS-. .- <br /> AgUl <br /> -1Lt_G1WUT INSPEC ION s� P I FINAL INSPECTION, <br /> INSPECTION BY=` , DATE 1$ INSPECTION BY DATE -fig <br /> E H 1426Rev. 1 74 r 3/?6 2M i . <br /> 1: . <br />