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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. r�y <br /> .� THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued <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 Regulati s of the San Joaquin Local Health District. <br /> 799a e. MlLrn"') - <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Emetine Bisso Phone <br /> Address 17990 E. !;;Ijl ton Road, =.inden, Cay if. 95236 City <br /> Contractor's Name Purviance Drillers,F'.O.Eox 64,Linden,Ca'i f. License # 24.01.07 Phone 931 -41,68 <br /> 952 <br /> TYPE OF WORK (Check): NEW WELL /_7 DEEPEN '#7 RECONDITION /-7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR -%J PUMP REPLACEMENT /x-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC 'TANK 751 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 75' 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 Existin IF we'1. ?.32' dee <br /> Domestic/private Drilled Dia. of Well Casing inst. O' of b 5/F;'2T.zner <br /> Domestic/public Driven Gauge of Casing 12 + <br /> Irrigation Gravel Pack Depth of Grout Seal 0. <br /> Cathodic Protection Rotary Type of Grout S <br /> Disposal Other Other Information .� <br /> GeophysicalSurface Seal Installed ,By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / State Work Done Re-install customer 2 hF pump <br /> r <br /> PUMP REPAIR: /_7 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 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 GROUTINGAND A FINAL INSPECTION. <br /> SIGNED TITLE Partner <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> - ---- � <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P II FINAL INSPECTION <br /> INSPECTION BY �� DATE INSPECTION BY LW44L DATE <br />.� E H 1426 Rev. -1-74 _ r 4/75- 2M --� <br />