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A SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 72 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE '.ISSUED Date Issued �1 <br /> (Complete In Triplicate) 2.�5 _caro <br /> Application is hereby made -to' the Sun 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. 1,862 and-the-Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Mi?-e East Vanx en,rP4. & , 001 North Allen Sd. CENSUS TRACT <br /> Owner's Name W. E. Alldrin Phone <br /> r <br /> Address 22877 North Ripon Road,. Ripon, Cal-if. 95366 � City <br /> Contractor's- Name Purvience-Dri?j-ers,P.a_.Bo7 61,;?,inden,.Ca-jif.,.yicense 240107 Phone 931-"68 c <br /> TYPE OF WORK (Check): NEW WELL /-7DEEPEN '/W RECONDITION /7 DESTRUCTION /_7 <br /> = <br /> PUMP INSTALLATION J / PUMP REPAIR -/_r / PUMP REPLACEMENT <br /> Other %// <br /> DISTANCE TO NEAREST: SEPTIC TANK ani, SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD j mi. <br /> CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELL ' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial = Cable Tool Dia. .of Well Excavation s g <br /> Domestic/private Drilled Dia. of Well Casing 1211 j <br /> Domestic/public Driven <br /> x IrrigationGauge of Casing Zq <br /> Gravel Pack Depth of- Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> -Geophysical <br /> Geophysil <br /> - Surface Seal Installed By:- <br />/PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . 4 /% State Work Done <br /> PUMP 'REPAIR-: -. #: /_7 `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 <br /> and the State of Cathe. San Joaquin Local Health Bistr <br /> lifornia pertaining to or regulating well `tonstruction. 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 REPORT of the well and notify them before putting.the..well, in.use.,:, _The_above' .. 4 <br /> information is 'true to the-hest-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 SIRE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED'BY DATE 3CI <br /> ADDITIONAL COMMENTS: . <br /> PHASE II GROUT INSPECTION', PHASE I FIN INSPECTION <br /> INSPECTION BY DATE / INSPECTION BY <br /> F 14 11.9 E <br />