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C 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. 76- /6„kj 1 <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued ��-2 <br /> (Complete In Triplicate) I <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 /> .TOB ADDRESS/LOCATION 12802 F. Jack Tone Road CENSUS TRACT <br /> Owner's Name- R. C. Foster Phone <br /> Address 1.2302 N. Jack Tone Road, T,6di, Ca7.if. 95240 City , <br /> Contractor's Name Purviance Drillers, Dox 64, Liriden, Ca". f. License # 240-107 Phone 931-4468 <br /> TYPE OF WORK (Check) : NEW WELL/_7 DEEPEN -/X7 RECONDITION /-V DESTRUCTION /7 <br /> PUMP INSTALLATION I / PUMP REPAIR '/? PUMP REPLACEMENT IF <br /> Other Ll — <br /> DISTANCE TO NEAREST: SEPTIC TANK 689 - SEWER LINES 781 - PIT PRIVY <br /> SEWAGE DISPOSAL FIELD' CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LIME PRIVATE DOMESTIC WELT,' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial x Cable Tool. Dia. of Well Excavation Existing., 811 <br /> X Domestic/private Drilled Dia. of Well Casing ,New inner: 6-5/8,, <br /> Domeatic/public _ Driven Gauge 'of Casing . 12 a - <br /> Ixxigatian Gravel Pack- ` Depth of Grout .Seal..Exist Ins <br /> Cathodic Protection Rotary Type of Grout f <br /> Disposal Other Other Information ' <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor y �% <br /> Type of Pump i , . H.P. € <br /> PUMP REPLACEMENT <br /> /g/ State Work Dane Replace!customer 'pump <br /> PUMP .REPAIR: / / State Work Done <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 LocalHealthDistrict <br /> and the State of California pertaining to or regulating well 'constxuction. 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 8DFINAL INSPECTION. <br /> SIGNED F TITL�I Partner <br /> DRAW PLOT PLAN ON REVERSE /SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> DATE `,;)-S '7 i� i <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY �• !� . DATE /Q <br /> i <br />