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t A <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS. OFFICE USE: 160] 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 2 <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 Joaquin <br /> Countiy Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> .TOB ADDRESS/LOCATION - 2001 West Gogna Road & j Mi. North Hwy 26 CENSUS TRACT , <br /> Owner's Name parry Celli. Phone ' <br /> Address P. 0. Box 241, Linden, Calif. 95236 City <br /> Contractor's dame Purvianee 1�riZlers, Boy- 64, Linden, �ali-f, License # 21+0-107 Phone 931--4468 <br /> TYPE OF WORK 3(Check):» NEW WELL 'I- -DEEP'ENA/—/ RECONDITION I I DESTRUCTION /-7 <br /> ,".PUMP INSTALLATION /x/ PUMP REPAIR / / PUMP REPLACEMENT /./-7 <br /> --,,.,;,,,Q then /1 f •-- <br /> DISTANCE TO NEAREST: SEPTIC TANK iii. SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF <br /> WELL CONSTRUCTION SPECIFICATIONS <br /> _ <br /> Industrial x Cable Tool Dia. of Well Excavation 14 S <br /> Domestic/private Drilled Dia. of Well Casing n <br /> Domestic/public 1 Driven Gauge of Casing - 10 ga t <br /> x Irrigation Gravel. Packf Depth of Grout Seal none <br /> OtherRotary Type of Grout <br /> Other Other Information ' <br /> 7 <br /> PLS.' INSTALLATION: Contractor Purulence Drillers ' <br /> Type of Pump Turbine H.P. <br /> PUMP REPLACEMMENT: / / State Work Done <br /> ` PUMP 3TPAIR �.•�-/�/--State Work'Done —"'"'^",� `'"" '_` <br /> DFTRUCTION QF WELL: ,; Well Diameter Approximate Depth <br /> ' Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the Statefof California pertaining to or regulating well "construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well; I will -furnish the Sah, .7vaquin Local Health District f <br /> WELL DRILLERS'tMPORT of the well and notify them before putting,'he�wrell�in-Wuse. The above <br /> xnf.orma�ori sue-�to,�tTie�3istwofu�y-kiowledge=and-"brief: <br /> T <br /> I <br /> SIGNED ' TITLE Partner <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> F DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED- . S DATE �/ 7 <br /> ,ADDITIONAL COMMENTS: <br /> PHASE Il GROUT INSPECTION PHAW]WI/FINa INSPECTION <br /> INSPECTION -BY DATE INSPECTION BrffZDATE 1 <br /> CALL--FOR-A-GROUTWINSPECTION•-PRIORTO GROUTING-AND FINAL INSPECTION. <br /> i - <br /> F�H 1426 �2- <br />