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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E Hazelton Ave. , Stockton, Calif. <br /> II` Telepthone: (209) 466-6781 <br /> i APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �7e-16,7,9 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> 4� (Complete In Triplicate) <br /> .. Allpplication 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. 1.862 and the Rules and Regulations of-the San Joaquin Local Health District. <br /> ' JOB-ADDRESS/LOCATION 3/1.0 11i?.e North Comstock & 7/10 j1i7 e E. Tul.1y CENSUS TRACT. <br /> Owner's Name` T, Samaado - Phone <br /> Address 8077 Iv Tull_y, 7.inden CGS if 9 52,q6. City. <br /> Contractor's Name,Purviance Dri�.1_ers P.G.Box 6 Linden Ca'! if. License # 240^f 0'7' Phone 931.7� 68 .� <br /> 52 6 -`J <br /> TYPE�OF W033K (Check) :' NEWPWEU___r EDEN /�] RECDNDITION Ix�T DESTRUCTION )R] <br /> PUMP INSTALLATION/ ] PUMP REPAIR/ / PUMP REPLACEMENT.,,-k-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK I mi1..e SEWER LINES PIT PRIVY <br /> 4 SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL ,. <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> `. Industrial s Cable Tool Dia. of Well-Excavation Ex s ingl_ s <br /> ., Domestic/private Drilled Dia.i of Well Casing to _-ns .. 1,U ' T,iner <br /> 1i Domestic/public Driven Gauge of Casing _ --10 <br /> fM Irrigation Gravel Pack Depth of Grout Seal +� r <br /> fM Cathodic Rrotection Rotary Type of Grout ~"b <br /> :M <br /> Disposal ., ` Other Other Information •�` L ""' <br /> .M Geophysical -ti Surface\Seal Installed B ,.i <br /> PUMP INSTALLATION: -Contractor { <br /> r <br /> Type of Pump P. <br /> ;PUMP REPLACEMENT: /X/ State Work Done Reinsta`i_Z customer 25 HP Turbine <br /> PUMP,-.REPAIR: Done <br /> BES,TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> . 3 <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 will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well`and notify them_beffore--putting ,the..well in use. The above <br /> information is -tru o_the bes-t-of my,knowl:edge'dnd. belief L , I WILL -CALL FOR..A_GROUT-INSPECTION <br /> . - - <br /> ;PRIOR-T0 G-ROIdTIN AN-� A FINAL- NS�PECTION- <br /> SIGNED _ ZZ TITLE Owner <br /> DiaW P T' PLAN 'ON REVERSE SI 77 77' <br /> ry . OR D PARTMET USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY .; DATE A d/- -7ff <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE IIT,/FINAL INSPECTION <br /> #. INSPECTION BY DATE _s INSPECTION BY DATE �2 - Ca <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />