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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> SOF: OFFICE USE: r '/ 1601 E. Hazelton Ave. , Stockton, Calif. <br /> I/ Telephone: (209) 466-6781 ' <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> f O Ij' .Th , �J T (Complete In Triplicate) X03 - Zao-�/ <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 and' the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 200' West of Jack Tone Rd, 4,� mile North Coppero12ENSUS TRACT <br /> Owner's Name Dan Brandstad Phone <br /> Address . 1090 E. Baker Road, Stockton, Calif. 95205 City <br /> Contractor's Name Purviance Drillers, Box 64, T.inden, Calif. License # 240107 Phone. 93i_-446g <br /> i <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /E7 RECONDITION tx-7 DESTRUCTION f <br /> PUMP INSTALLATION / / PUMP REPAIR /� PUMP' REPY,ACEMENT <br /> Other I/—/- <br /> DISTANCE <br /> /;DISTANCE TO NEAREST: SEPTIC TANK .$00l SEWER LINES PIT PRIVY <br /> SEWAGEIDISPOSAL 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 <br /> Domestic/private .'Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> �- Irrigation i ',Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 4P Rotary Type`-of`-Grout <br /> Disposal ► Other _ Other Information 10"x TO ga col-. may be Inst. <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor Purviance Dri7-1.-ers H.P. 75 <br /> Type" Pump _ Turbines � <br /> J <br /> PUMP REPLACEMENT-. [State Work Done <br /> tState Work Done i <br /> PUMP '.REPAIR: <br /> i Approximate Depth <br /> E DESTRUCTION OF WELL: Well' Diameter <br /> Desc�ibe 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/f.urnish the San Joaquin Local Health District <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 A FINAL I SPECTION. I TITLE - Im`ey <br /> SIGNED <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPAR T USE ONLY <br /> PHASE I 4ij <br /> - /APPLICATION-ACCEPTED,BYADDITIONAL COMMENTS: PRA INSPECTION <br /> PHASE II GROT INS ECTION INSPECTION BY DATE 6— <br /> INSPECTION BY ► DATE <br /> L , 5 2M <br /> F K TG7fi RAv_ 1-7 G. <br />