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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR!OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Caiif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,PV- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> �> F (Complete In Triplicate) <br /> Application is hereby made to the Sat: Joaquin'Local Health District for a permit to construct <br /> and/or instar. the work herein described. This application is made in compliance with San Joaqu#n <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION. 1.6909 SOUTH VAN .ALLEN ROAD CENSUS TRACT <br /> Owner's Nampa Bob Spurgeon Phone Unlisted <br /> Address" . 'Same-"- City Escalon <br /> Contractor's Name T .D. S-utt aixd\:,Sfn _�2\ �;��� ��License # 279010 Phone 838-2207 � <br /> 71 <br /> TYPE OF WORK (Check) :v NEW WEI;Ia%fit+ 'DMOE9d?/7 RECONDITION`17 'DESTRUCTION /=7 <br /> PUMP INSTAi;LATI4�i / ./,,,]w REPAIR / --.PUMP REPLACEMENT 17 <br /> . Other l <br /> vj <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY4, tggjy , Lv <br /> } SEWAGE DISPOSAL FIELD 1 CESSPOOL/SEEPAGE PIT OTHER <br /> �- PROPERTY LINE - PRIVATE DOMESTIC-WEL�� PUBLZCJDOMEBTIC WELL , <br /> INTENDED USE TYPE OF WELL G CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dil. of Well Excavation <br /> Domestic/private Drilled { Di-e. of Well Casing <br /> � a <br /> Domestic/pubJlic T - Driven Gauge of Casing-- <br /> Irrigation <br /> asing Irrigation Gravel Pack i Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other f OtFier Information <br /> Geophysical 'Surf ace Seal Installed By: C' <br /> 77 <br /> PUMP INSTALLATION: Contractor ° <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /3 State Work Done Remove Jet Pump and Install Sub. <br /> • PUMP :REPAIR: _�� -'� <br /> —S�a•te-Wotic-Doae�- - --- <br /> - - oS� BJH \2AA <br /> ,DESTRUCTION OF WELL: Well Diaper 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 willifurnish 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 FINAL INSPECTION. <br /> SIGNED TITLE Partner <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I E <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS_ : <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY,44 _ DATE ,/775_�9 .9</ <br /> ! E H 1426 Rev. 1-74 1-74 2M <br />