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( � JOAQUIN LOCAL HEALTH DISTRIC <br /> F0 'OFFICE USE: I60... _. Hazelton Ave. , Stockton, Cal-x,. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ;7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUE <br /> i v <br /> (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 worts herein described. This application is shade in compliance with San Joaqui <br /> County Ordinance No. 1.862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> ,j <br /> JOB ADDRESS/LOCATION East side Clements Road, North nide Dead-end Erandt CENSUS TRACT <br /> mail �'. <br /> 9 • <br /> Owner's Name Darwin T�ewis Phone <br /> Address 23709 E. Brandt Road, T,odi,. Cal-if. .95240 City.' <br /> Contractor's Name Purvianee Drill-ers,Eox 64,T,inden,Ca�if.95236License # 2407107 Phone 931-4468 <br /> TYPE OF WORK (Check) : NEW WELL '/—/ DEEPEN -/7 RECONDITION /-7 DESTRUCTION 1-7 <br /> PUMP INSTALLATION / / PUMP REPAIR '/r7 PUMP REPLACEI22T.; /J <br /> Other <br /> .DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> 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 Cable Tool Dia. of Well Excavation <br /> �w Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> X Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection, Rotary Type of Grout <br /> Disposal Other Other Information ' is <br /> Geophysical -- --- Surface Seal Installed By: <br /> s <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump !iH.P. <br /> PUMP REPLACEMENT: /—x/ State Work Done- Repair and repT_aee original pump <br /> PUMPI.REPAIR: / / State Work Done . . . . . <br /> DESTRUCTION OF WELL: Well Diameter Approximate.-Depth <br /> E 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 the well and notify them before putting. the..well in.use. .. The above <br /> informs an s tr he- est.of my.knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR GR TI AL INSPECTION. <br /> SIGNS �, TITLE Partner <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> R DEP TMENT USE ONLY <br /> PHASE I r <br /> APPLICATION ACCEP DATE / >/'����✓ <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASF0I;Z/EP#L INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 3 <br /> E H 1426 Rev. .1-74 <br />