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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE'; 1601 E. Hazelton Ave. , Stockton, Calif. <br /> r <br /> Telephone: (209) 466--6781 <br /> IM APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. - 33 O . <br /> �. THIS PERMIT EXPIRES1 YEAR FROM DATE ISSUED Date Issued 6-2A-2 7 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct I <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 /> - y <br /> JOB ADDRESS/LOCATION 320' Vest Sec Tgpe & 1. Mi. South Hwy 26CENSUS TRACT <br /> Owner's Name joi Brandstad e: Phone C <br /> AddFess 1 d��Jack Toneoo ,St oc_k u_oni_Calif'S 95205 City � <br /> Contractor's Name, Purviance Drill ers,P.O. Box 64,I,inden,Cal if License # 240107 Phone 931=4,468 <br /> _----- - <br /> TYPE OF WORK (Check) : NEW WELL /x/ DEEPEN /_/ RECaNDITION / / D-ESTRUCTION %xT <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT IxT <br /> '. Other / / — <br /> I <br /> DISTANCE TO NEAREST: SEPTIC TANK 1001 , SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD- 1009 CESSPOOL/SEEPAGE PIT OTHER <br /> I PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS _ <br /> Industrial x Cable Tool. Dia. of Well Excavation 8" <br /> r x Domestic ' <br /> /private Drilled Dia. of Well Casing 8" <br />�'"�� Doiriestic/public Driven Gauge of Casing 10 1 <br /> Izrigation ' Gravel Pack Depth of Grout Seal. 50' � ! <br /> Cathodic Prot ction Rotary Type of Grout Neet Cement <br /> Disposal Other Other Information 1.21' Conductor i e -for cket: <br /> Geophysical % Surface Seal Installed BY: <br /> I� 5 I r I <br /> PUMP INSTALLATION: > Contractor i <br /> Type of ;Pump s - - - - - - H.P. <br /> PUMP REPLACEMENT: <</x/ Staie'_Work_DM_ Reinsta'1.1 customer' <br /> PUMP .REPAIR: ? / / Stat7Watk .Done <br />-- .. ,�- ....,� - s -4 - <br /> DESTRUCTION,"OF ELL: 'Well D= -iameter 8" Approximate Depth 130' <br /> _...-Describe Material'(and Procedure,. Packfij! with soil 50t .from . dT <br /> � 'cement to 4" of surface 4rlle/� _ <br /> I hereby agree I'to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining tour 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 GROUTI G D A FINAL INSPECTION.', <br /> SIGNED a . 'y TITLE 1e ' <br /> DRPig T PLAN 'ON REVERSE SIA ) <br /> AW <br /> I FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY HATE27 <br /> ADDITIONAL COMM'}NTS: <br /> PHASE II GROUT INSPECTION PjaSE II FINAL INSPECTION <br /> I SPECTION BY IM., DATE -._INSPECTION B DATE <br /> �DId i�4;701d <br />.4 1426 Rev. 1-74 5e& pa_m'_� V <br />