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r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> T FOAr_OFFICE USE: 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 r Data 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 a d1the Rules and Regulations of the San Joaquin Local Health District. <br /> 11/y r 0I� f F. /& <br /> ,t <br /> JOB ADDRESS/LOCATION Mile Worth Arch Road & 'jMile Wiest 99 Frontage CENSUS TRACT <br /> 6wner4s Name Frank Gianneechini ; Phone <br /> Address - 1.9+00 E. Hnry 26, TAnden, Calif. 95236 City <br /> Contractor's Name Purviance Dri.i-jers P.O.Eox'61+,Linden,Ca].if. License # 22401.07 Phone 931--x.!}68 <br /> TYPE OF WORK (Check).; NEW WELT, /_7 DEEPER "/-- RECONDITION Ix-T =DESTRUCTION "/ j ; <br /> PUMP,INSTALLATION /f/ PUMP REPAIR / / PUMP REPLACEMENT #"7 <br /> Other / <br /> DISTANCE TO NEAREST':--SEPTIC TAN .1-t SEWER LINES PIT PRIVY R <br /> r. SEWAGE�DISFOSAL;FIELD`- 2l)0 CESSPOOL/SEEPAGE PIT OTHER <br /> 'PROPERTY LINE.---PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE .OF_WELL CONSTRUCTION SPECIFICATIONS K <br /> Industrial x Cable Tool Dia, of Well Excavation -case eRlsting We11K <br /> Da�estic/priyate --' Drilled Dia. of Well Casing with 1411 re deepen <br /> Domestic/public '. Driven , Gauge of Casing 1' <br /> x Irrigation Gravel-Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal :' Other Other Information <br /> Geophysical r Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT:•--/X`/- StaCe <br /> PUMP, ]REPAIR: / State Work Done _.T. <br /> ,RESTRUCTION OF WELL: Well',Diameter k. Approximate•,Depth <br /> Describe Material and Procedure' a <br /> .. I <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_..will4furiisl the San Joaquin Local Health District a <br /> WELL DRILLERS.-REPORT -of the well-and notify them before putiting the.,well in-.use.. The above <br /> information is true fo' the 'beit of my knowledge and belief. I WILL CALL FOR A'GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. � <br /> SIGNED "- TITLE Partner <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR .DEPARTMENT USE-ONLY <br /> PHASE I - <br /> APPLICATION ACCEPTED BY t DATE 22_2_22 <br /> ADDITIONAL COMMENTS: � <br /> PHASE II- GROUT INSPECTION P E JallyIN INSPECTION <br /> INSPECTION BY DATE ,r INSPECTION BY �m !_DATE <br /> ! E H 1426 Rev. 1-74.. ��� c.� d /-7�z _ �,�• ? <br /> 1-74. 2M <br />