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yr <br /> ,. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. (a- &_) <br />'i 76 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued ��6. <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 Regulations' of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 164.46 E. Copperopotis Road CENSUS TRACT <br /> Owner's Name Elmo-Ba-cchini Phone ' <br /> Address 3.61,.4.6 .E. Copperopolis Road, Linden,,, Calif. City <br /> Contracto s Name Purvience Dri?lers, Box 64, Linden, Calif. License # 240-1074 Phone ��� ' <br /> 68 <br /> TYPE OF WORK (Check): NEW WELL '%/ DEEPEN '/-7 RECONDITION DESTRUCTION r7\ <br /> t PUMP INSTALLATION / PUMP REPAIR /`7 PUMP REPLACEMENT f 77 <br /> e.i Other /_7 �R <br /> F � - <br /> DISTANC. .,TO�NEAREST: S P ,TANK,3_0_P'- SEWER.:LINES-� -�--T-'RLVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL -SEEPAGE PIT OTHER . <br /> _ ,.. , .--. _... s <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL' �',A PUBLIC DOMESTIC WELL\ �W <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONSIo, N <br /> Industrial a Cable Tool Dia. of Well"Excavation 1411 <br /> Domestic/private Drilled Dia. of Well,,Casing 14 <br /> Domestic/public Driven Gauge of Casing171.6 Fl-aTe - <br /> z Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout. <br /> Disposal Other Other Information ' <br /> ( Geophysical Surface Seal! Installed Bys -__-- <br /> PUMP INSTALLATION: Contractor Purviance Drillers f <br /> Type- of Pump TurbineH.P. <br /> k PUMP REPLACEMENT: - / / State Work Done <br /> 3 <br /> ! PUMP .REPAIR: /_7 State Work Done f ' <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 `constructionf Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San JoaquinfLocal Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting.;the..well.,in.use... The above <br /> information true t e b f my.knowledge and'•-b'61ief:'�4 WILL CALL r`.FOR'A GROUT INSPECTION <br /> ,PRIOR TO--GROU NG A. I ECTION. <br /> SIGNED Nc_ TITLE Partner <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPABIMT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE - �S <br /> ADDITIONAL COMMENTS: <br /> PHASE Il GROUT-,INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ^7 . <br /> E H 1426 Rev. 1-74 - 4/75 2M <br />