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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F7.-."-- OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: . (209) 466-6781 n�� r <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7f, `f(�f <br /> THIS PERMIT EXPIRES .1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> plication.-is hereby made to the San Joaquin Local Health District for a permit to construct <br /> .-Id/or install the work herein described This a lication. is made in compliance with San Joaquin <br /> / FP F <br /> :ounty Ordinance No. 1862 and the Rules and Regulations of .the San Joaquin Local Health District. <br /> F__iB ADDRESS/LOCATION South side Milton Road & T IvTie.fest Deitrich Rd. CENSUS TRACT <br /> er's-Name Ik?6rman Gerber Phone <br /> rress 1995 E. i Y ton HtiadT ens Calif. 95236 City <br /> �99 . <br /> ntractor's Name Purviance Drip-?etirs 1'.G.Hox 6� Ta nden Cal if. License 4� '24010 Phone 931:468 . <br /> 9 523 <br /> �1 <br /> [PE OF WORK (Check) : NEW WELL /X/ DEEPEN / / RECONDITION /_-7 DESTRUCTION /-7 JV <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP. REPLACEMENT /7 <br /> Other <br /> I:STANCE TO NEAREST: SEPTIC TANK 1001 SEWER LINES PIT PRIVY <br /> SEWAGE„DISPOSAL FIELD xOpt CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL _"01' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL_ "- CONSTRUCTION SPECIFICATI.O_NS_ , <br /> Industrial X Cable Tool Dia. of Well Excavation 12" <br /> Domestic/private Drilled Dia. of Well Casing 12 <br /> Domestic/public Driven Gauge of Casing YO <br /> a Irrigation Gravel ,Pack Depth of Grout Seal <br /> Cathodic Protection Rotary' Type of Grout s <br /> F_Disposal Other Other Information <br /> -L-Geophysical Surf ace Seal Installed By: <br /> ]MP INSTALLATION: -Contractor <br /> 1 Type of Pump H.P. <br /> REPLACEMENT: . /X/ State Work Dome Inst al.1_ Customer 3Q HP Turbine <br /> T <br /> �JMP .REPAIR: / / State Work Done <br /> s <br /> E S•TRUCTION OF WELL; Well Diameter � Approximate Depth <br /> Describe Material and Procedure <br /> ;hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> id 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 /> LL DRILLERS REPORT of the well and notify them before putting the..well in use. The above <br /> formation is true to a best of my.-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> -LL <br /> TO GROUTING A.ANAL INSPECTION. <br /> SIGNED ' TITLE <br /> DRAW I'L T' PLAN ON RE FRSE SID ) <br /> • FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> %,PPLICATION ACCEPTED BY ATE <br /> V.DDITIONAL COMMENTS: <br /> PHASE ,II GROUT INSPECTION 1' SEIIII197AL INSPECTION <br /> r'J'SPECTION BY DATE I+I PECT10N SATE 7-9At <br /> _ <br /> 3/76 2M <br /> R <br /> 14 1d7Fi RAv- 7-71L r �- <br />