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,R <br /> 4P SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOfi;OF'FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 21Qi <br /> 76- 3f---I <br /> THIS PERMIT EXPIRES 1 YEAR>FROM DATE -ISSUED Date Issued - -7� <br /> VQ { (Complete In Triplicate) 2D3^oeo2j <br /> Ap-licatian"ig"hereby~made-Fto-thd Sun Joaquin Local 11calth District for a permit to construct <br /> and/or .install the work heroin described. This application is made in compliance with San Joaquinl <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 8/10M, S. French Camp Rd./800' E. North Ripon 'P4-CENSUS TRACT <br /> Owner's Name Angelo Stagnaro Phone ' <br /> Address 18011 E. Messick Road, Linden, Calif. City . . <br /> Contractor's Name Purvianee Drillers, Box 64, Linden, 001f. License # 240-107 Phone 931-4468 <br /> TYPE OF WORK (Check) : NEW WELL/i7 DEEPEN '/7 RECONDITION /7 DESTRUCTION J7­ p <br /> PUMP INSTZLATION ,/x/ PUMP REPAIR /_7 -PUMPS REPLACEMENT /7 ' <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK miles SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD _ CESSPOOL/$EEPAGE PIT OTHER <br /> PROPERTY. LINE •- PRIMATE DOMESTIC WELL' :—' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial x Cable Tool Dia, of Well Excavation 11+11 <br /> Domestic/private Drilled Dia. of Well Casing TV <br /> Domestic/public Driven Gauge of Casing 10 <br /> x Irrigation Gravel. Pack Depth of Grout Seal <br /> Cathodic Pr_otect_ion Rotary Type of Grout - <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed 'B <br /> PUMP INSTALLATION.- Contractor Purvianee Drillers <br /> Type of Pump Turbine H.-P.- 30 <br /> _ ! <br /> 'UMP REPLACEMENT: . / / State Work Done . . � <br /> PUMP ,REPAIR: / / . 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 s rue o t -b of my..knowledge and belief. I WILL CALL FOR-A GROUT INSPECTION <br /> PRIOR TO�ROUT G NSPECTION. <br /> SIGNED TITLE Partner lk <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ,. <br /> APPLICATION ACCEPTED BY 2,:;:' r,- DATE <br /> ADDITIONAL. COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS I N NSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> �? a •t��� a,.__ �.. _ ..._. .�_ <br />