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SAN JOAQUIN LOCAL HEALTHDISTRICT <br /> FOS'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 7 _ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. L�7� <br /> THIS PERMIT ;EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7d <br /> �Q_xZO. N Sft6ctF. <br /> '. (Complete In Triplicate) i <br /> ,lpplication is Hereby made to the San Joaquin Local Health District for a permit to c8itruct <br /> and/or install the work herein described. This application is made in compliance with .San Joaquii <br /> (ounty Ordinance k6. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> OB ADDRESS/LOCATION 710 Mile East Shelly Road , South Hwy 26 CENSUS TRACT 047-290-F, <br /> errs Name Charles Moody Phone <br /> Address 800 14th Street, Modesto,.,Ce7if. 953% City <br /> ti. <br /> contractor's Name Purviance Dri]leirs,F.O.Box 64,Linden,Ca7i£. License /i 740107 'Phone -931:4468 <br /> 952367 <br /> �YPE OF WORK (Check) a NEW WELL -/g/ . DEE'PEN--j—_7 RECONDITION_/./-'. DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUP9P REPAIR-/_/=-PUMP .REPLACEMENT LT - •�.T <br /> Other / / rQ <br /> iISTANCE TO NEAREST: SEPTIC TANK -1001 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 x Cable Tool -,Dia: of Well Excavation <br /> Domestic/prfvate Drilled Dia.' .of Well Casing Su <br /> Domeatic/public Driven Gauge of Casing 10 <br /> _ Irrigation Gravel Pack Depth of.Grout Seal 5D j <br /> Cathodic Protection Rotary` Type of Grout 2 part sand l part Cement 4 <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed Bye <br /> ALLATION$ Contractor <br /> Type of Pump H'.P': <br /> 'UMP REPLACEMENTi / / State Work Done <br /> UMP .REPAIR: j / State Work Dote <br /> STRUCTTON OF WELL: Well Diameter Approximate Deptti <br /> Describe Material and Procedure <br /> hereby agree to comply with.all laws and regulations of the San Joaquin Local Health District <br /> Ind the State of California pertaining to or regulating well'construction. Within FIFTEEN DAYS <br /> fter completion of my work on a new yell,, I will furnish the San Joaquin Local Health District a <br /> TELL DRILLERS REPORT of the well and notify them before putting the .well in use. The above <br /> reformation is true to the best. of my-kno�;ledge, and belief.. I WILL CALL FOR A GROUT INSPECTION <br /> IOR TO GROUTING DFINAL I SPECTION.14 e <br /> IGNED 4' -, TI-TLE <br /> DRAW-Pre PLAN ON PITERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> RASE I <br /> PPLICATION ACCEPTED BY DATE <br /> IDITIONAI; COMMS TS: <br /> P E GROUT INSPECTION PHASE /F QAL INSPECTION <br /> NSPECTION BY DATE d INSPECTION BY .a� DATE 0 <br /> �� <br /> ' E H 1426 . Rev. 1-74 " " 3/76 2M <br />