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�a <br /> ' SAN JOAQUIN LOCAL HEALTH DISTRICT - <br /> FOFIMFICE 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 FRON DATE ISSUED Date Issued 3�/3 <br /> C i:� '?.$' (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 : <br /> County Ordinance No. 1862andthe Rules and Regulations of the San Joaquin Local Health District. ; <br /> i <br /> JOB ADDRESS/LOCATION" J5 Mi, North Hwy 26 & .1 Ali. West Finasco Road_ CENSUS TRACT t9Sf--(,w .3 <br /> Owner's"Name Louis Rubino Farms Phone <br /> Address = -- - 1M08 E. Hw_y 26, Linden, Calif. 95236 ._ City <br /> Contractor's Name Purviance Drillers P.O.Box 64 Linden., Calif-License # 240107 Phone 931-44.68 <br /> 95236— <br /> 5 <br />�x'YPE;.OF WORK (Check): --NEW--WELL /7 DEEPEN / RECONDITION -/7 DESTRUCTIOX= <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP kEPLACEMENT /R7 L1 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK .15 i SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD .15 MiCESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL'.,15MiPUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial x Cable Tool Dia. of Well Excavation Existing-IT' Well <br /> DomRstic/private'- Drilled Dia. of Well Casing Inst. 10-3/4" Liner <br /> Doma•stic/public Driven Gauge of Casing .188 Wa14 <br /> X Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout N r <br /> Disposal Other Other Information <br /> Geophysical. 'Surface Seal Installed By: <br /> PUMA INSTAL ,_ ; Contractor�- <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done Install customer. "Turbine <br /> PUMPiREPAIR: L-T State"Work Done L <br /> EES,FRUCTION OF WELL: Well Diameter -,, Approximate Depth <br /> Describe Material and Procedure <br /> 4 <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 coattuction.-;-MW-:Lthin..FIFTFFN 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 /> information is true to the-best'of. my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND FINAL INSPECTION. <br /> SIGNED t TITLE Partner <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> I ; C� FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ; DATE Zz"iz z <br /> ADDITIONAL COMMENTS: <br /> PHASE II -GROUT INSPECTION PHASE I I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 1 ~E H 1426 Rev. 1-74 `.` 7 �-. .� ;, c �� 1-74 2k <br />