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j� SAN JOAQUIN LOCAL REALTH DISTRICT <br /> _Fo OFFICE USE: 1601 E. Hazelton Ave`:°;.-.Stockton, Calif. <br /> R Telephone: (209). 46676781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�-1�a. <br /> THIS PERMIT EXPIRES- 1 .YEAR :FROM DATE ISSUED Date Issued/p J9 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Locax:. 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/LOCA7TION S/W Corner Murphy and Maxiposa. Roads CENSUS TRACT j d'3--0?0�c7 <br /> Owner's Name Vineyard. Properties of California Phone <br /> Address City <br /> Contractor's Name Sta.nislaus Pump & Machinery Corp, License # A290355 Phone 522-9027 <br /> * m <br /> TYPE OF WORK (Check):- NEW WELL;/ —DEEPEN /? RECONDITION /_� DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR /x/ PUMP REPLACEMENT 17 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY tc�p� <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> r INTENDED-USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation ' ' <br /> x Domestic/private Drilled Dia. of Well Casing <br /> F Domestic/public Driven Gauge of Casing ' <br /> S 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 - �ana.slatitis Pum}i& machin (!n=_ <br /> Type of Pump Tirrh!-ne H.P. ]0 � <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP !REPAIR: /L State Work Done Rebearing, Motox <br /> 2ES:TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Matertial and Procedure - - - <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br />� L and the State of California pertaining to or regulatiing 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 QROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> gV ,,. DRAW PLOT PLAN ON REVERSE SIDE <br />` : FOR DEPARTMENT_USE ONLY <br /> PHASE I - - <br /> APPLICATION ACCEPTED BY �'t/b �` DATE y�2� <br /> ADDITIONAL COMMENTS: <br /> PHASE II ROUT INSPECTION, '`', PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE` ��INSPECTION BY � ' DATE Idl/7-Y _ <br /> i I E H 1426 Rev. 1--74 1.-74 2M <br />