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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: PP 1601 E. Hazelton Ave. ,- Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION, OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued 2 y1i <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. 1$62 andvthe 'Rules and Regulations of the San Joaquin Local Health District. <br /> r,'Z3 7LC1 rF1�=[_�41�'c PB�I�=,�0,., 2-a-7- r7 o--o k <br /> JOB ADDRESS/LOCATION. side Mari osa Rd 1.0 Mi. E o Dodds' Rd. Jot. CENSUS TRACT - <br /> Owner's.-Name + Ed LeiRplt Phone 838-2839 <br /> Address 23UI E Mariposa Road City Escalon <br /> Contractor's Nanie - Purvianae Drillers ; License # 240-107 Phone 931-"68 <br /> l <br /> TYPE-OF WORK (Check) :'--NEW--WELL's/��/ 'DEEPEN .F/7 RECONDiTION�/_7 DESTRUCTION/7 <br /> `PUMP INSTALLATION I1CI PUrU' REPAIR 'I / PUMP REPLACEMENT /7 <br /> Other <br /> IN <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY �- <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation- <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gratel Pack Depth of Grout -Seal <br /> Other Rdtary Type of Grout <br /> Uther Other Information ' ' <br /> PUMP INSTALLATION: Contractor PUrvignoe Dginers. 4- <br /> Type of Pump Tuxhine Exating) H.P. '20 <br /> PUMP REPLACEMENT: / / State Work- Bone <br /> PUMP REPAIR: / / State Work Done <br /> ;7- <br /> .DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to compl" ' 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. <br /> SIGNED ' t TITLE $=3d=m Partner <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PWV II W4AL INSPECTION <br /> INSPECTION BY DATE INSPECT ON BY DATE - <br /> CALL F'OR .A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 4/72 1M <br /> E H 1426 <br />