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1�1 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOB:OFFICE USE: {,. 1601 E. Hazelton Ave., Stockton, Calif. <br /> ,. Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1,I7b F <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 Jomquin <br /> County Ordinance No. 1862 and the Mules and Regulations of the San Joaquin Local Health District. <br />'3'-q 3 g' IA/ .`�o r=./--< � '44 <br /> JOB ADDRESS/LOCATION Mi• S' Hwy 120:�� 1 M" 'W• McKinley CENSUS TRACT <br /> Owner's Name Terra Development - Phone <br /> Address 5151 E. A?-moundwood Drive, Manteca,'Galif. city , <br /> Contractor's Name Purviance Drillers, Box 64, Linden, Calif: License # 240-107 Phone 931-4468: . <br /> TYPE_OF WORK_(Cherk-)-:—NEW-WELL-/-7—DEEPEN"Y7 RECONDITION DESTRUCTION /? � 3 <br /> PUMP INSTALLATION ,6[ / PUMP.'REPAIR EM <br /> /-7 Pump REPLACENT /7 w <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE z-- PRIVATE DOOMES�'IC WELL PUBLIC DOMESTIC.WELL <br /> INTENDED USE TYPE OF WELL . CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia: of Well Excavation "`h <br /> Domestic/private Drilled ' —' Dia. of Well Casing r <br /> Domestic/public Driver: Gauge of Casing <br /> X Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed 'B <br /> JUMP INSTALLATION: Contractor Purviance Drillers <br /> Type of Pump Turbine H.P. 40 <br />; PUMP REPLACEMENT:. / / State Work Done <br /> PUMP ,REPAIR: - / / State Work Dome <br /> DESTRUCTION OF WELL:M1 " TWell 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 Distri; t ' <br />'sand the State of Califa.tnia pertaining to or regulating well"construetion. Within FIFTEEN DAY <br />, after completion of my'work on a new well, I will furnish the San Joaquin Local Health District ,— <br />,,WELL DRILLERS REPORT,of the well and notify them before putting. the .well in-use.. The above <br /> information] rue to my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO ROUTI GAN A F ECTION. <br /> SIGNED TITLE Partner <br /> 4 DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> , APPLICATION ACCEPTEDIBY DATE ` Z-- <br /> ' ADDITIONAL COMMENTS: 4 <br /> PHASE II GROUT INSPECTION PHASE 1112 FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BYAe <br /> ATE �Z'_/6- <br /> V V 1L7G n . t- 7/. h/75 2M' <br />