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f Mw SAN OAQUSN LOCAL HEALT IDIS ► ujolftUt or�n4 — -.--- <br /> FOFirOFFTGE USE: 1601 E. Hazelton Ave. , Stockton, Calif. 11" <br /> I Telephone: <br /> I APPLICATION FOR WELL CONSTTRUCTION6OR1FUMP PERMIT p / / <br /> Permit No.����(�l4 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) 3—ate~07 <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 /> f County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> -42,0 D AJ: <br />' JOB ADDRESS/LOCATION 1 2/10.Fmile E o_ le <br /> ine Rd 500' S of Mormon CENSUS <br /> Owner's Name Moto�.ke�x ou � -__- ,___-- TRACT <br /> - Phone '73) D251 <br /> Address 00 <br /> City Linden <br /> Contractor's Name Purvian Ce Drillers <br /> License # 240107 Phone 931-LP+68 <br /> TYPE OF WORK Check): "NEW WELL -/71-EEPEN <br /> � 7 RECONDITION /_� DESTAUCTION /� <br /> PIMP INSTALLATION%-/ PUMP REPAIR / / PUMP REpLACEDXjT G <br /> ' Other ET <br /> � f <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD `�` <br /> CESSPOOL/SEEPAGEPIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL '. PUBLIC DOMESTIC WELL <br /> INTENDED l TYPE OF WELL f <br /> industrial .- _ ._CONSTRUCTION SPECIFICATIONS ' <br /> Domestic zZZZ� Cable fool Dia. of Well Excavation ,f <br /> /private Drilled Dia. of Well 'Casing ex sist in 12 <br /> =:_. Domes.tic%public <br /> Driven Gauge of Casing znst7 i <br /> Irthxigatiori - Gravel Pack Depth of Grout S10 last 1Oa <br /> Caodic P=_otection Rotaryeal <br /> _ _Disposal Type of Grout <br /> —Geophysical Other Other Information <br /> Surface Seal. Installed B : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> _ - <br /> PUMP REPLACEMENT; <br /> / / Statei Work Done H.F. <br /> PUMP'' PAIR: /7 State Work Done <br /> ES'TRUCTION OF WELL: Well Diameter -' <br /> Approximate Dep h <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 wel <br /> after completion of my work on a new welll construction. Within FIFTEEN DAYS <br /> DAYS <br /> I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before puttingthe 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 GROUTING A FIN INSPECTION; <br /> SIGNED - <br /> TITLE Partner <br /> (DRAW PLOT PLAN ON REVERSE 5IDE) <br /> PHASE I 6 FOR DEPARTMENT TTSE ONLY <br /> APPLICATION ACCEPTED BY - <br /> ADDITIONAL COMMENTS: DATE _ <br /> PHASE II GROUT INSPECTION - - <br /> INSPECTION BY DATE P L E III FI INSPECTION j <br /> r ] �( IN ECTIoN_.BY - DATE <br /> i [ U P USE {IJ�Lj; �c1 ry�! q l L4 b 4b a +, <br /> d <br /> E H 1426 b Mi'-I �u� ►�, Ot°y.° r.��.{( Y�2s�r� �„� t Cfp�S�o <br /> Rev. ]-74 �. r � <br />