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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOIA OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. a_/4 g_,;4_ <br /> • THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued /, ,,,4?>g' <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 � Mi't e East Kaiser Road & I j-hUle, South Mariposa RdGENSUS TRACT <br /> Owner's Name Joseph Safi uinetti Phone <br /> Address ?_8626 E. Coppero2olis %d, Linden, Ca?,if. 05236 City <br /> Contractor's Name Purviance Dril l-ers P.0.Box 64j,inden.,Ca7 if. License # 240107 Phone -931�4468 <br /> TYPE OF WORK (Check) : NEW WELL / /. DEEPEN IX—1 RECONDITION_ / DESTRUCTION /7 <br /> w PUMP INSTALLATION. /X/ P'UMP"REPAIR % / PUMP REPLACEMENT <br /> Other 17 <br /> DISTANCE TO NEAREST: - SEPTIC TANK blijes 'SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD Miles CESSPOOL/SEEPAGE PIT OTHER <br /> 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 Existing 16" <br /> Domestic/private Drilled Dia. of Well Casing To instal-I. J411 Diner <br /> Domestic/publicDriven- Gauge of Casing 10 <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 /> PUMP INSTALLATION: Contractor Purvianee Drillers i <br /> Type of PumpTurh;ne - -- H•P• 100 <br /> PUMP REPLACEMENT. / / State Work Done <br /> PUMP .REPAIR: / /' State Wok 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 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 /> SIGNED TITLE Partner <br /> DRAW- Ph T PLAN ON RE ERSE SIDE <br /> FOR DEP4&TMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE gLALMNAL .INSPECTION <br /> INSPECTION BY DATE INSPECTION BY AA, -DATE s-/y_e-a_ <br /> 3/76 2P4 <br /> F H 1426 Rev. 1-74 r�[o►�� �i�►� 0 d17'�/w` / <br />