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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO&;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 77- <br /> � <br /> THIS PERMIT .EXPIRES 1 YEAR FROM DATE ISSUED Date Issued jz& <br /> (Complete In Triplicate) /a S -- r(a0- <br /> Application is hereby-made to l,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 andthe Rules and Regulations of the San 'Joaquin Local. Health District. <br /> JOE ADDRESS/LOCATION 600' 'Pest Flood Rd, 1 mile South Hwy 26 CENSUS TRACT � <br /> - E <br /> 3 <br /> Owner's Name Dal. Porto Farms, Inc. Phone <br /> Address P. 0. Box 21:.72 Linden, Cal-if. 95236 City y <br /> Contractor's Name Ross Purviance License #180532 Phone .867-3480 f <br /> 1 <br /> TYPE OF WORK_ (Check) : NEW WELL ]z7 DEEPEN '/-7 : RECONDITION /_7 DESTRUCTION f7.- , <br /> PUMP INSTALLATION /i/ PUMP REPAIR'/ SPUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 1251 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL �] <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �s <br /> Industrial -fit Cable Tool Dia. of Well Excavation Ilt« <br /> Domestic/private "° Drilled Dia. of Well Casing 14" <br /> Domestic/public 1, Driven Gauge of Casing 10 ea <br /> X Irrigation ii Gravel Pack Depth 'of Grout Seal <br /> Cathodic Protections -. Rotary Type of Grout <br /> Disposal Other- Other Information ' <br /> Geophysical. Surface Seal Tnstalled"„By: <br /> PUMP INSTALLATION: . Contractor Ross Pu:rviana® <br /> Type of Pump _.Turbine H.P. " O <br /> PUMP REPLACEMENT / / Sbate Work Done <br /> PUMP ,REPAIR: / / Sta'te,Work Done' <br /> DES<TRUCTION OF WELL-:_. Well�b ameter 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. =,-kthin 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 /> informationtru to the-best ,of.-my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TOG ING D A F NAL INSPECTION. <br /> SIGNED TITLE Omer l <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BY DATE '3--V "7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PRASE III FINAL INSPECTION <br /> - I <br /> INSPECTION BY DATE . INSPECTION BY DATE <br /> E H 1426 .. �t�v_ 1_74 - L/75 .. 2M — -, <br />