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JOAQUIN LOCAL. HEALTH DISTRICT <br /> FQEOFFICE USE.: 1601 E. <br /> Hazelton Ave. 2 Stockton, Calif. <br /> ` <br /> ' I phone: (209) 466-6781 <br /> T 'dN ( WELL CONSTRUCTION OR PUMP PERMIT Permit No. � <br /> t?77ERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued iS-2.7 <br /> (Complete In Triplicate) <br /> Application is b,403' Joaquin Local Health District fora permit to construct <br /> ` This application is made in compliance with San Joaquin <br /> and/or install thelo�slHaig� S ribed. <br /> i County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> * z 7 CENSUS TRACT <br /> JOB ADDRESS LOCATION t 1.1 Mi. East Hewitt Road & I Mi. North Hwy 4 <br /> Owner's Naiae r Steven'San uinett i Phone <br /> Address 170 South Drais Road Stockton Calif. 95205 City <br /> iv <br /> Contractor's Name Purvianee Drillers Box 64.linden.,Cal..if. License # 24 1.07 Phone , 2 1-1,46$ <br /> TYPE. QFYWORK _{Check) : -NEW�WELL-%W�-DEEPEN /V/.�RECONDIT-1ON_t/ =-*DES-TRUCT-1ON /� = <br /> PUMP INSTALLATION / PUMP REPAIR/ / PUMP REPLACEMENT 17 <br /> Other [-7 <br /> M <br /> DISTANCE TO NEAREST: SEPTIC TANK •SEWER LINES PIT PRIVY _ �" ' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT . ,OTHER :: Q <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL "N <br /> INTENDED USE, R. TYPE OF WELL CONSTRUCTION SPECIFICATIONS Q <br /> Industrial x Cable Tool Dia, of Well Excavation 14" Q <br /> Domestic/private i <br /> Drilled Dia. of Well Casing 14" <br /> Domestic/public Driven Gauge of Casing 10 <br /> X Irrigation Gravel. Pack Depth of Grout Seal ✓ <br /> Cathodic Protection j Rotary Type of Grout <br /> Disposal 1 Other Other Information <br /> Surface Seal Installed By: <br /> Geophysical <br /> PUMP INSTALLATION: Contractor Purviance Drillers H.P. <br /> Type of Pump . Turbine [ i <br /> PUMP REPLACEMENT: / / State Work Done <br /> _4 f <br /> PUMP .REPAIR; <br /> / / State Work -Done <br /> . r <br /> DESTRUCTION OF WELL: Well Diameter � - Approximate Depth �_, <br /> _— Describe Material:and-Procedhre=- _ <br /> - <br /> j 1 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 completion of my work on a new well,,' I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPORT of the well and A.. 4y them before putting the well in use. The above <br /> information is true to the best of 'my'.knowledge and belief. l WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTI G D A FINAL.`INSPECTION. TITLE �� <br /> f SIGNED ' � <br /> D W PI; T' PLAN ON RE PRSE SIDEi <br /> t FO ARTMENT USE ONLY,, - .�- <br /> PHASE I . E DATE <br /> APPLICATION ACCEPTER YCM �P <br /> ADDITIONAL: COMMENTS: - �l PHASE III/FINAL INSPECTION <br /> PHASE II GROUT-INSPECTION <br /> INSPECTION BY 'r DATE INSPECTION BY `j� DATE S •,,I ° <br /> �•=.— . . -- — " }3/76 2M <br /> E H 1426 Rev. 1-74 <br />