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SAN JOAQUIN LOCAL HEALTH. DISTRICT ' <br /> FOE OFFICE USE: J 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone.: (209) 4.66-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76_-s9#_ <br /> 76-/--'/AP J0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 6 /,(,_;9 <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 Stn Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of -the San Joaquin Local Health District <br /> JOB ADDRESS/LOCATION SOt West Van All en Road & Mi. South'? CENSUS TRACT /e3 - 2eo-D5' <br /> Owner's Name Steven Sanguinetti Phone <br /> Address 170 S. Drais Road, Stockton, Calif. City <br /> Contractor's Name Purviance Dri?.jers,Box 64,7inden,Calif. License # 240-1-07 Phone 93!-4468 <br /> 95236 2 <br /> TYPE OF WORK (Check): . NEW- WEL-L /_7 -DEEPEN /_/ PRECONDITION /x7 DESTRUCTION %f <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /x7 <br /> Other J-7 <br /> DISTANCE TO NEAREST: SEPTIC TANKMi.SEWER LINES PIT PRIVY �~ C) <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER m <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial x Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> x Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information Clean out san ,ins .diner <br /> Geophysical Surface SealInstalledBy: <br /> Sr <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /x/ State Work Done Replace existing irrigation Turbine 2ump <br /> PUMP -REPAIR: / / State Work Done <br /> DES-TRUCTION 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 is true to the-beat of myknowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND INAL INSPECTION. <br /> SIGNED TITLE Partner - <br /> D W- PLAN 'ON REViRLSE SID_E�_ � <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I , <br /> APPLICATION ACCEPTED BY DATE / 2-- <br /> ADDITIONAL iCOMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION . <br /> INSPECTION BY DATE INSPECTION BY s DATE V-2 7� <br /> E H 1426 Rev. 1-74 V76 2K <br />