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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stocktou, Calif. <br /> Telephone: (2.09) 466-67081 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 72- 76 g <br /> E <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED ' Date 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 s <br /> County Ordinance No: 1862 and- the Rules and Regulations of the San Joaquin Local Health District. j <br /> i.. <br /> JOB ADDRESS/LOCATION South side Flood & 1 mile East Fine CENSUS TRACT ' <br /> Owners Name'' ;:W. F. Nan Passel Phone <br /> ' a <br /> Address 2116 Coronet Blvd. Belmont, Calif. 9!+002 City <br /> Contractor's Name Ross Purviance License # 180532 Phone 887..,3./.8C) ' <br /> TYPE OF WORK (Check) : NEW WELL '/7C/ DEEPEN '/—/ RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT /7 4 <br /> / <br /> Other.t/ N ,' <br /> E DISTANCE TO NEAREST: SEPTIC TANK 1151 SEWER LINES 115' PIT PRIVY <br /> SEWAGE DISPOSAL ,FIELDr CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial X Cable Tool Dia. of Well Excavation 12- ' <br /> 4 .; <br /> x Domestic/private Drzlled* Dia. of Well Casing 8 <br /> Domestic/public Driven Gauge of Casing 10 <br /> Irrigation Gravel Pack Depth of Grout Seal 60 <br /> Other Rotary Type of Grout Neet <br /> T Other "'" Other Information 121' Conductor <br /> 1- <br /> PUMP INSTALLATION; Contractor <br /> Type of Pump H.P. <br /> PUMP 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 C <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 PORT of e well and notify them before putting the well in use. The above <br /> information s Ile <br /> t t,_ best of my knowledge and belief. r <br /> SIGNED ; TITLE Owner <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br />� PHASE I /! <br /> APPLICATION ACCEPTED BY DATE. 7' " 72- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY � er d,DATE _7 - Q--, INSPECTION BY DATE Vk <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP ON. <br /> E H 1426 4/72 IM i <br />