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JOAQUIN LOCAL HEALTH DISTRICT � <br /> Fo ;aFFICE USE: 1601. Hazelton Ave. , Stockton, Calms_. �YK <br /> Telephone: '(249) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-1;-D Y <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1 '3-0`'7, <br /> 1 {Complete In Triplicate) <br /> Application isAiereby mode 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 Joaquit <br /> County Ordinance No. 1862 and the Rulea and Regulations of, the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION +4 Mile East Clements Rd. & *4 Nile North Comstock SUS TRACT ' <br /> Owner's Name Webster Rand Phone <br /> E <br /> Address 8712 K. Clemente .Road, Linden, Calif. 95236 <br /> City. <br /> Contractor's Name Purviance Drillers�P.0 Box 64Linden Ca1it. License # 2.40107 Phone. 931-4.4.68 <br /> j <br /> 95236 <br /> TYPE OF WORK (Check) : NEW WELL -/ / DEEPEN /_X7 RECONDITION DESTRUCTION <br /> 1-7 <br /> PUMP INSTALLATION / / PUMP REPAIR :/_7 PUMP REPLACEMENT <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 WELT, <br /> s. INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS U <br /> Industrial # x Cable Tool Dia. of Well Excavation s ng I <br /> Do eestic/private i- Drilled Dia, of Well Casing Inst, 121i Liner ?v <br /> Domestic/publi.cDriven Gauge of Casing �p <br /> X Irrigation - Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal ( Other Other Information C <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor` F <br /> Type of Pump H.P. . <br /> PUMP REPLACEMENT: <br /> Ll State Work Done ' . <br /> PUMP !REPAIR: <br /> / / State Work Done \ <br /> DESTRUCTION OF WELL: Well. D ameter 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 />?RIOR TO GROUTIN FINAL INSPECTION. <br /> SIGNED <br /> TITLE Partner <br /> 1 (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I . FOR DEPARTMENT USE ONLY <br /> 4PPLICATION ACCEPTED BY. DATE 3 d <br /> kDDITIONAL COMMENTS.. ' , , <br /> PHASE II GROUT INSPECTION PHASE I F AL INSPECTION <br /> INSPECTION BY DATE INSP CTION BY DATE a <br /> • li�� 77 wtnr,cam...u . . �-fi <br /> E*H' 1426 Rev. 1-74 /►�rou 1��,� ,� o,; Ce,,_ ,S • F.117c eiu <br />