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S JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOR OFFICE USE: 1601 Hazelton Ave. , Stockton, Cal. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, L -825e <br /> THIS PERMIT EXPIRES :1 YEAR FROM DATE ISSUED Date Issued _T-IL77 <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 work herein described.. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 an'd� the Rules and Regulations of the 'San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 75' North Frazier hd. Mile East Cleffients Rd. CENSUS TRACT <br /> Owner's Name John Lewe1.l an 11 Phone <br /> Address 87 .2 N. Clements tr.oad Linden, Calif. 95236 City <br /> Contractor's Name Furvia:nce Jri11.ers,t.O.Eux 644 indein,Ca1 if-License # 240107phone 937-"68 <br /> 95236- <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN -/ / RECONDITION C/ DESTRUCTION /'7 <br /> PUMP INSTALLATION -/x/ PUMP REPAIR/ / PUMP REPLACEMENT 1_7 <br /> Other i/ ./ <br /> 1 ,.w <br /> DISTANCE TO NEAREST: SEPTIC TANK 8 ►a�i.SEWER LINES PIT PRIVY <br /> SEWAGEDISPOSAL FIELD 3 8 L.i.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 /> Domestic/private i- Drilled Dia. of Well' Casing <br /> Domestic/public ; Driven Gauge of Casing <br /> X Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection I Rotary Type of Grout _ <br /> Disposal { Other Other Information <br /> Geophysical Surface Seal. Installed By: <br /> PUMP INSTALLATION: Contractor Purviance Drillers <br /> Type of Pump Turbine H.P. 50 <br /> 3.nst•a11. pump in existing __ Well) <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP .REPAIR; /7 Sl ate 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 notifj)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 F'INALI INSPECTION. <br /> SIGNED <br /> TITLE <br /> MEW P Of PLAN 'ON REVERSE LID <br /> FOR DEPARTMENT <br /> 6 USE ONLY <br /> PHASE I n <br /> APPLICATION ACCEPTED BY DATE _��j-rI+ r <br /> ADDITIONAL COMMENTS: 1 <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION .BY DATE I <br /> E H 1426 Rev. 1-74 3/76 2K�C. <br />