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t3ob td - S4-L"`' SAN JOAQUIN LOCAL HEALTH,DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. } <br /> Telephone: - (209) =466-67817�r Qom/ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7y� <br /> THIS PERMIT EXPIRES .1 YEAR FROM DATE ISSUED Date Issued (,-/I- <br /> (Complete <br /> _/ -(Complete In Triplicate) '_ <br /> Application -is hereby fiade tot'the San Joaquin Local Health District for a permit to construct <br /> . This -application 'is made in compliance with San Joaquin <br /> and/or install the work herein described <br /> County Ordinance Nd. 1862 and; the Rules and Regulations .of the San Joaquin .Local Health District. <br /> JOB ADDRESS/LOCATION South side Milton Road &� �UJE `Rest Deifric_ Rd. CENSUS TRACT <br /> Owner s Name <br /> Forman Gerberi Phone <br /> Address 19958 E. ii�ton Road _�en, Calif'. - 95236 City <br /> 1 <br /> Contractor's Name Purviance Dri'+.7_ers P.O.Box 64 Linden Cal if. License # ?1,0 07 Phone 93 --L,l�b$ `I <br /> 95236 <br /> TYPE OF WORK (Check) : NEW WELD/Sc/' DEEPEN / / RECONDITION /_7 DESTRUCTION,1_7_ <br /> �_-_A!Urlp R NSTAI LATYON '/'�I 7_PUMP-aREPAIR*/--/--PUMP"REPLACEMENT <br /> �.. Other 77 <br /> DISTANCE TO NEAREST: SEPTICiTANK 1-001 " SEWER'LINES PIT PRIVY <br /> SEWAGE' DISPOSAL FIELD 1001 CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL _5G PUBLIC DOMESTIC WELL <br /> INTENDED USE' TYPE OF WELL-:' CONSTRUCTION SPECIFICATIONS � . <br /> 2" <br /> Industrial I..S Cable Tool Dia. of Well Excavation l <br /> I Drilled Dia. of Well Casing 12 <br /> Domestic/private <br /> _ Domestic/public 1 Driven~ Gauge of Casing 10 <br /> x I� r igatioii 1 Gravel .Pack Depth of Grout Seal <br /> Cathodic Protection 1 Rotary; ' *� ':., �TYPe' of Grout <br /> Disposal i�_ Other _-- Other Information <br /> Geophysical r "^ Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor _ N H.P. <br /> t <br /> Type of .Pump m <br /> ' . <br /> 4 PUMP REPLACEMENT: / S:tat_e-Work=`Done IiiSI;a91'=Customer-X30.- '�Ttzrbine <br /> PUMP .REPAIR: / / 'State Work Done M1 <br /> DESTRUCTION-OF�WEL3;t' °��.Well :Diameter <br /> _ (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 /> f information is true to a best of my knowledge and be I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUSING A NAL INSPECTION. <br /> SIGNEDTITLE �14P77 1 <br /> �DW`_P1T! T__`P_____LAN' ON RE RSE SID ) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 3 I..: _ <br /> } APPLICATION ACCEPTED BY <br /> ATE <br /> F ADDITIONAL COMMENTS ' ° ' -, <br /> 1 - P SE I AL INSPECTION <br /> PHASE II GROUTIINSPECTION <br /> INSPECTION BY # DATE NSPECTION SATE <br /> E ;y 4r..a 3 76 2M <br /> E H 1426 �_ Rev. 1--74 <br />