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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F05 OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued k�0 <br /> �44LOI %/ 10 Plication <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 Joaqui. <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 1 <br /> OB ADDRESS/LOCATION 7/10 M le Fast Shelly gond , South Fwy 26 CENSUS TRACT d4`7_ ;Z90_/,? <br /> �wc�er'a Name Ch,Fies Koodg' <br /> ■ Phone <br /> 11 <br /> Address 800 14th Street, Modesto, Ca7.if. 95354 � City <br /> contractor's Name Purvianee Dri»,ergs P.O.Brix 61.,73ndeo,Ce' f, License # 21,.0107 Phone 931-V,(8 <br /> �YPE OF WORK (Check) : NEW WELL /X_7 'DEEPEN /7_ ,RECONDITION /_-7.FDESTRUCTION /7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/_/ PUMP REPLACEMENT /� <br /> Other `/ _ <br /> / — <br /> ISTANCE TO NEAREST: SEPTIC TANK ?0 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 100' CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL-- <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial { 2 Cable Too1� �'''~ 'Dia.)of 'Well Excalation 6" <br /> R Domestic/private - Drilled , ?,-� <<Dia. of Well Casing, n �- <br /> ■ Domestic/public 1 Driven ���. Gaiuge of.Casing <br /> C Irrigation 'Giavel Packs D'epth ofcGrou0 Seal §0 <br /> Cathodic Protection Rotary ' Type of Grout 2 part saxxi 1, art Cement <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> )UMP INSTALLATION: Contractor, V <br /> Type of Pump H.P. <br /> _ k <br /> Done <br /> 'UMP REPLACEMENT: State Work_ ` r <br /> / / <br /> Im REPAIR: /_7 State,Work Done <br /> ,ESTRUCTION OF WELL: Well Diameter <br /> 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 /> d the State of California pertaining to o_r regulating well construction. Within FIFTEEN DAYS <br /> ter completion of my work on anew well, I will furnish the San Joaquin Local Health District a <br /> TELL DRILLERS REPORT of the welljand notify them before putting the .well in use. The above <br /> formation is true to the best of-my. knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> IOR TO GROUTING AN FINAL I�SPECTION`c' _� \N <br /> GNED ° TITLE _ <br /> DRAW P T' PLAN:'ON REVERSE. SIDE) P?v! ' <br /> SE I FOR DEPARTMENT USE ONLY <br /> PPLICATION ACCEPTED BY DATE . ��" <br /> DITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> SPECTION BY DA1TE INSPECTION BY DATE <br /> ' E H 1426 Rev. 1-74 3/76 2M <br />