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SAN ,10,%QtTT11 LOCAs. HEA.LT11 DISTRICT <br /> FF10E USE: ~ 1601. E, 11n7clton Ave. , Stockton, Calif. <br /> _.E _ Telephone: (209) 466-6781 <br /> _ APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2,7-8; <br /> --- - I ;: 7-,9#rTHIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> ration is hereby made to the San Joaquin Local Health District for a permit to construct <br /> Install the work herein described. This application is made in compliance with San Joaquin <br /> Ordinance No. IS62 and the Rule; and Regulations of the San Joaquin Local Health Dibtrict. <br />.)DRESS/LOCATION i-1.r0 Mile 6/10Ylest Jnck Tone & �i0 Mile South 1*i�ht CERRu ° cT <br />'a Name Den Brandstad _ _ _ Phone <br /> es 11090 E. bake>i road, Stockton, Cniif. 95kO5 City <br /> actor's Name Furviance Dri'iers,Lox 64,T,inden,Ca'If.95236License A 240-107 Phone 931•-44q <br /> OF WORK (neck): NEW tH, T,L Lf T)FF.T't'.Nj RCCONDITTON_ A bESTPUCTION <br /> PUMP INoTALLe,TION /X/ PIR& REPAIR LJ PUtiP REPLACEMENT /-T i <br /> Other E/_ <br /> !r <br />,VCE TO NEAREST: SEPTIC TANK6/10 SEWER LINES FIT PRIVY , <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPng3 PIT OTHER <br />_ PROPERTY LINE - PRIVATE DOMESTIC WELL — PUBLIC DOMESTIC WILL <br /> INTENDED TISE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial x Cable Tool Dia. of Well EXCaoation r <br /> Dome!ntic/private Drilled Dia, of Wali CAsing <br /> Domestic/public Driven Gauge of CEaing _. <br /> Irrigation _r Cravel Pack Depth of Grout goal <br /> Cathodic Protection Rotary Type of Grout _ <br /> Dispoaal Other Other Information <br /> out ne . •r <br />-Geophysical Su-face Seal Installed By: <br /> INSTALLATION: Contractor Furvionce Drill .rs <br /> Type of TurbinePump— H.P. <br /> REPLACEMENT: L-7 State Work Done <br />.REPAIR: /_7 State Work Done <br /> RUCTION OF WELL: Well Diameter Approximate Depth , <br /> Desc-she Materia_'. and Procedure <br /> reby agree to comply with all lawn and regulations of the San Joaquin Local Health District <br /> the State of Call:ornin pert.n!ning to or regulating well construction. Within FIFTEEN DAYS <br /> r completion of my work on a ne., well, I will furnish the San Joaquin Local Health District a <br /> DRILLRRS REFORT of the well and intify them before putting the well in use. Ths above <br /> rmntion is true to the beet of my knowledge and belief. I WILL CALL FOR A GROUT LNSPECTION <br /> a_TO GROUTINGi AWA FINAL, INSPECrioN. <br /> TITLEv-, <br /> DRAW P I'LnN ON REVERSE SID 1` <br /> .. FOR DEPARTMENT USE ONLYLc�/ 1 <br /> KATION ACCF.FTRD 11Y T` -=` :i DATE <br /> TTnNAL r0MM!NT9t - <br /> -'- FNAbR..IYI[i.,t1AI.. INSPtCTI0 j <br />