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F <br /> GROUTING SCH. FOR 1:30 Fri.-9/76/77' <br /> 9/?6/77 <br /> �. 11 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 1 <br /> F0_K7QFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 _="L <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.;7 O <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued - ill <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 /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS LOCATION 8001 East Jack Tone Rd. & 318 lvil,e South Barney Lan@ENSUS. TRACT <br /> Owner's Name Ken HardinPh <br /> one <br /> Address 9214 West, Vane, Stockton, Calif. 95207 � City , I <br /> Contractor's NamePurviarce Drillers,P.-O..Ebx 6lj.Anden,Ca7� f`. License # ,240107 Phone 931-446 � <br /> TYPE OF WORK (Check): NEW WELT, /17 EEPEN /7 RECONDITION /_7 ESTRUCTION a <br /> CATION /7-pump REPAIR /� PUMPCEi1EN <br /> Other <br /> DISTANCE TO NEAREST: .SEPTIC TANK 900T-. SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 9001 CESSPOOL/SEEPAGE PIT ' OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL � I <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS- <br /> Ind strial <br /> PECIFICATIONSIndustria, x Cable Tool Dia. of Well Excavation 811 v <br /> x Domestic/private Drilled Dia. of Well Casing 81, <br /> Domestic/public_ Driven Gauge of Casing 12 <br /> Irrigation Gravel, Pack Depth of Grout Seal 55' <br /> �.' Cathodic Protection �� Rotary Type of. Grout, deet Cement i <br /> Disposal. ` - f'. Other Other Information Jacket Conductor 2ipe - _ 2" � <br /> Geophysical Surface Seal Installed By, <br /> X St ock - - - <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP ,.REP R; / / State Work Done ry <br />�'DESJRUCTION OF WELL: Well Diameter 1-0 Approximate Depth 70' <br /> Describe Material and Procedure Backfi , soll- to 501 -� Cerent to surface <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 /> information is true to-the-best-of.-my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING A FINAL INSPECTION. <br /> SIGNEDTITLE Partner <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FO TMENT US ONLY <br /> PHASE I <br />�APPLICATION' ACCEPTED BC • DATE '//A <br /> ADDITIONAL COMMENTS.- <br /> PHASE <br /> OMMENTS:PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ! - -6 'r 7 <br />