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+ SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICAT 'ON)FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. f p <br /> THI - PERMIT. EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> r (Cofmplete In Triplicate) <br /> Application is hereby made to the Sdn Joaquin-Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in comp'�iance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS LOCATION ide d 3A lvdle North Comstock Rd. CENSUS TRACT © VS10-I <br /> Owner's Name lawrence Sarabado Phone <br /> Address 5077 Iii. Tully Road, T,inden, Calif. 95236 ➢City <br />. Contractor's Name Furviance Dril-lers,F.O. ox 64,7,inden,Calif. License #1240107 Phone 931./.468 <br /> 552 <br /> TYPE OF- WORK (Check) : - , NEW_-WELL /_�j--DEEP��-,/_.7/ —RECONDITION x/ DESTRUCTION <br /> PUMP INSTALLATION ,� PUMP REPAIR / / PUMP REPLACEMENT L_x7 <br /> .O.ther <br /> DISTANCE TO NEAREST: SEPTIC TANK r500' SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 500' CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL ''PUBLIC DOMESTIC WELL ­4 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial x Cable Tool Dia, o Well Excavation Existing14" Nel.T <br /> Domestic/private Drilled. Dia. of Well Casing to instal 1, 1211 Liner <br /> Domestic/public- Driven Gauge of Casing 10 <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 By: <br /> 4 <br />-PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /x/ State Work Done Re lace Customer 25 HP Turbine <br /> PUMP .REPAIR: J / 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 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 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 GROUTIN D A FINAL INSPECTION. <br /> SIGNED TITLE <br /> f DRAW POT PLAN ON RE FRSE SIDE <br /> PHASE I <br /> F04 -DEPARTMENT USE ONLY <br /> � - - <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ty <br /> E H 1426 Rev. 1. 74 / 3/76 2M <br /> 1 <br />