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SAN JOAQUIN LOCAL HEALTH DISTRICT <br />FOIr .0:CE ;US 1601 E. Hazelton Ave: , Stockton, Calif. <br />` Telephone: (209) 466--6781. <br />APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br />i <br />THIS: PERMIT EXPIRES 1 YEAR FROM :DATE.ISSUED Date•lssued <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'hereiri described. This application is -made in compliance with San Joaquin) <br />County Ordinance -'N6. 1862 and"the Rules and Regul tions of the San Joaquin Local Health District. <br />30B ADDRESS/LOCATION 7.% bile _forth Hi?dreth & I Mile East 99.Frontage CENSUS -TRACT <br />Owner's Name- Doug Edge <br />Address 5347 Hi'Idretq Lane, Stockton, Cal if.`95212 <br />Phone � ' 661 th <br />City <br />01.Contractor's Name Ross Purvian a D.ri1.Iing, P.O,Box 185,tinden License # 180532 Phone' 8$fi� g0 <br />J.a1_ 95236 <br />,.. i <br />TYPE OF WORK (Check): NEW WELI` /g% DEEPEN'/_% RECONDITION f—/..DESTRUCTION 1-7 <br />AL <br />PUMP INSTI?ATION /x/ PUMP REPAIR /_7 PUMP REPLACEMENT /7 <br />Other /. / <br />F <br />PHASE I <br />APPLICATION ACCEPTED BY <br />ADDITIONAL COMMENTS: q <br />ENSPECTION BY <br />E H 1426 <br />'44,0 <br />DATE 61 171 <br />R�v,.1-7 3/76 2M <br />DISTANCE TO. NEAREST: <br />'SEPTIC TANK 200' SEWER LINES PIT PRIVY <br />' <br />SEWAGE DISPOSAL FIELD 200' CESSPOOL/SEEPAGE PIT OTHER <br />PROPERTY. LINE - PRIVATE DOMESTIC WELL' w PUBLIC DOMESTIC WELL <br />INTENDED USE <br />TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br />Industrial - <br />_ j.x Cable Tool Dia, of Well Excavation <br />x Domestic/private Drilled Dia.'of Well.Casing 811_ <br />Domestic/public <br />! Driven ,. Gauge' of Casing 12, <br />..' <br />Irrigation <br />f Gravel Pack' %f_,_ Ddpth of Grout Seal 50' <br />Cathodic Protection i Rotary1. r Type of.Grout T�eet Cement - 70 ax mix. <br />Disposal <br />Other..- _ ; �'--Other Information' <br />Geophysical <br />/ Surface Seal. Installed By:����y� <br />PUMP INSTALLATION: <br />Contractor Ross-Purviance Drij.1ing , <br />Type dot, Pump .SW=6fraible It H.P. <br />PUMP REPLACEMENT: <br />/ / State Work Done <br />PUMP .REPAIR: <br />/ / State Work Done <br />DESTRUCTIONOF WELL: <br />o <br />J' <br />Well' Diameter" Approximate Depth <br />Describe Material and Procedure - - <br />I hereby agree to comply with all laws and regulaf1-on9'of 'the San`Joaquin Local Health District <br />and the State of California <br />pertaining to or regulating well -construction. Within FIFTEEN DAYS <br />; <br />after completion of my work on,a new well, I will furnish the San Joaquin Local Health District <br />a- <br />IWELL DRILLERS REPORT <br />of�the_wglml and notify them before putting the.well in use. The above <br />information s . trt the <br />u <br />-bent" of. my.. knowledge and belief. I WILL CALL FOR' A GROUT INSPECTION <br />'RIOR TO OU ING D <br />A FINAL .INSPECTION. <br />>IGNED <br />TITLE Owner <br />DRAW PLT PLAN ON REE SE SIDE). <br />FOR DEPARTMENT USE ONLY <br />PHASE I <br />APPLICATION ACCEPTED BY <br />ADDITIONAL COMMENTS: q <br />ENSPECTION BY <br />E H 1426 <br />'44,0 <br />DATE 61 171 <br />R�v,.1-7 3/76 2M <br />