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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> . /FOSrOFFICE 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 <br /> 4 (Complete In Triplicate) <br /> Application is herby made to the San Joaquin Local Health District for 'a permit to construct <br /> and/or install the work herein described. This .appllcation .is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of- the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CT <br /> l4 <br /> Owner t s Name .doe Nome'!7"ini � 'A Phone <br /> Address 1-3084 E. Flory 262 Stocktori, Cai-if. 95205 City <br /> Contractorts Name,Purviance Dritlers,P.O.Box 64,Unden,. Cal-if-License # 20107 Phone 931.4.468 <br /> 4 <br /> F � <br /> TYPE�OF WORK"(Cheak)-:�ANEW.,WELL -/_7 DEEPEN / RECONDITION /W DESTRUCTION /7 <br /> PUMP`INStAI�UAT.ION,/%-.PUMP.REPAIR`S/�`/ PUMP REPLACEMENT Other ti Other <br /> DISTANCE 'TO NEAREST: SEPTIC TANK _ 1.Q0t''"' SEWER LINES PIT PRIVY' <br /> SEWAGE DISPOSAL FIELD 1001 CESSPOOL/SEEPAGE PIT OTHER <br /> j - J ­,PROPERTY-,,LINE==.PRIVATE DOMESTIC WELLPUBLIC DOMESTIC WELL' <br /> INTENDED USE TYPE OF WELL a CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable,Tool Dia. of Well Excavation Existing T411 <br /> Domestic/private Drilled Dia. of Well Casing to inst. 12 Laver <br /> _ Domestic/publicDrivent Gauge of Casing 3 J- Plate <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 /> PUMP INSTALLATION: Contractor WN <br /> Type of Pump S.P. <br /> PUMP REPLACEMENT: %/ State Work Done <br /> PUMP :REPAIR: /-7 State Work Done <br /> ,DES.'TRUCTI(}N' OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree i. to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State- of California pertaining ;to or regulating veil construction. Within FIFTEEN DAYS <br /> after completion of my work on a new'wrell,9",I.,will furnish the .San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and natiify 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 TQ GROUTINP AMA FINAL.INSPECTION., <br /> SIGNED o TITLE -artner <br /> 4 44 <br /> DRAW,.PLOT PLAN ON REVERSE SIDE <br /> -;-FOR DEPARTMENT USE ONLY <br /> PHASE I t '>° DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: 3, <br /> f PHASE II GROUT INSPECTION PHASE /112fgNa INSPECTION <br /> INSPECTION BY# , DATE - _ , INSPECTION BY DATE Z <br /> s , ch - <br /> t ~E H 1426 Rev. 1-74 1-74 2M <br />