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/ SAN JOAQUIN LOCAL HEALTH DISTRICT y <br /> 70E7OFFICE USE: 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �- 7kJ <br /> -7,6, 6 /0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ['720 9 . 140LL,,C' ,pSCC�4- 4.6- (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 /> . County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Mi. N. Hwy 4 & lj Mi. E. Jack Tone CENSUS TRACT <br /> Owner's Name John Ratto Phone <br /> Address 2297 N. Duncam 'Road, Linden, Calif. City <br /> ' � <br /> Contractor's Name Pu.rviance Drillers, Box 64,, Linden, Cal f. License # .240-107 Phone 931-4468 <br /> TYPE OF WORK (Check) : NEW WELL /7 DEEPEN A-7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION PUMP REPAIR /-7 PUMA' REPLACEMENT )J � <br /> Other j/7 <br /> DISTANCE TO NEAREST; SEPTIC TANK mixes SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL ' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial a Cable Tool Dia. of Well Excavation 1211 <br /> Domestic/private Drilled Dia. of Well Casing 3211 <br /> Domestic/public Driven Gauge of Casing 10 C 3 <br /> x Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By:' <br /> PUNK' INSTALLATION: Contractor Purviance Drillers <br /> Type of Pump Turbine H.P. 404 <br /> PUMP REPLACEMENT: • /sJ State Work Done Re-install customer 40 HP Turbine Pip <br /> PUMP :REPAIR <br /> _ • / / State Wank Dane ,r <br /> �1 <br /> DESTRUCTION OF 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 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 a <br /> WELL DRILLERS REPORT of the well and notify° them before putting the..well. in.use... The above <br /> informatio true t est of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO.GROU IN. IN INSPECTION. <br /> SIGNED TITLE Partner <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY' DATE <br /> ADDITIONAL COMMENTS; <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE Z-/e YA <br /> E H 1426 Rev. 1-74 r' 4/75 2M <br />