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1'5'1-6W SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: - (209) 466-6781 <br /> APPLICATION.FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. l�"QbS <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date •Issued (S-19-7z) 's <br /> j (Complete -In Triplicate) 5 y <br /> Application `is hereby trade toi' the San Joaquin Local Health District fora permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 andi"the Rules and Regulations of the San Joaquin Local.Health District.' <br /> JOB ADDRESS/LOCATION North side T&jhut rivet Mile East Wall Load -CENSUS TRACT Dei/--3LO <br /> Owner's Name David Mi!,ler Phone- <br /> Address,— <br /> honeAddress• 20475..E, Walnut Drive, .Iinden, Calif. 95236 City <br /> 1 � <br /> Contractor's Name Purvianee Drill-ers,P.O.,Eox bJ� ,1•inden,Calif, License # 240'107 Phone 93j-74LS_ <br /> - 95236 <br /> W TYPE OFWORK ,(Check) _NEW..WELL / DEEPEN /_/V� RECONDITION._:/_--/:.--DESTRUCTION,/?---... <br /> PUMP INSTALLATION/ / PUMP REPAIR / / PUMP REPLACEMENT 17 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK 651 SEWER LINES PIT PRIVY. <br /> SEWAGE DISPOSAL FIELD 80' 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 /> .„g._—Domestic/privat'e Drilled Dia, of Well Casing 8" <br /> Domestic/public Driven. Gauge of Casing 7-2 <br /> Irrigation f Gravel Pack Depth of Grout Seal 0= <br /> Cathodic Protection 1 Rotary Type of Grout 2 sand to 3_ Cembnt <br /> Disposal 1 Other Other Information t <br /> Geophysical: � Surface Seal Installed By: I <br /> PUMP INSTALLATION: Contractor <br /> { Type of Pump H.P. <br /> t <br /> PUMP REPLACEMENT: . /x/ State Work Done Replace Customer pump <br /> PUMP .REPAIR: / / State Work Done <br /> 1 -rrr✓ .-.. 'www?Y?t y. <br /> DESTRUCTION OF WELL; Well Diameter Approximate Depth <br /> T :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 State of California pertaining -to or regulating well '-construction. Within FIFTEEN DAYS <br /> after completioneof my work on.,,a new well, I`Will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of- the"we'1'1"4and notify them before putting the well in use. The above <br /> information' is true to the best of ,my knowledge, and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AN FINAL! IN VECTION. <br /> SIGNEDTITLE W _ <br /> . ;� .. 14 <br /> DRAW PL T PLAN 'ON RE )ARSE SID"2) .. r <br /> -FOR--DEPARTMENT USE ONLY Y ,• - _.^,� _. - <br /> PHASE I _ _ _7 <br /> 4 Y 4 <br /> APPLICATION ACCEPTED By,1�+ -_ -- _-- DATE <br /> ADDITIONAL COMMEN <br /> P GROUT• INSPECTION PHASE III/FINAL INSPECTION j <br /> INSPECTION BY DATE INSPECTION BY � A4 DATE <br /> 9/7b 2M <br /> E H 1426 Rev. 1.-74 ;. <br />