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- s <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF210FFICE USES' 1601 E. Hazelton Ave. , Stockton, Calif. I <br /> IE I "' Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT . Permit No.7 7 <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued fD / ;l <br /> (Complete In Triplicate) <br /> Application is hereby made t� the San Joaquin Local Health District 'for a permit toconstru <br /> ct <br /> and/or .install the work herein described. This application is made in compliance with .SanJoaquin <br /> I County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local. Health District. <br /> JOB ADDRESS/LOCATION 300'' South H 26& .S Mii.e East Waj,j Rodd CENSUS TRACT <br /> -Owner's Name JohnILIaV � <br /> ; { Phone ' <br /> ,Address el' 873 N. Wal Road Linden, Calif. 95236`_ -. <br /> City.. <br /> Contractor's Name Purvience DrilZers,P.O.Box 6/:,Linden,Ca.1_it- License # . '?�0107 Phone 931 x.68 <br /> 4 . <br /> TYPE OF WORK (Check): 3NEW WELL /x? DEEPEN /_7 RECONDITION /? DESTRUCTION /-7 <br /> PUMPVINSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT % 7 <br /> Other f/ / <br />,DISTANCE TO NEAREST: SEPTIC TANK 7_00' SEWER LINES _ PIT PRIVY <br /> F SEWAGE ,DISPOSAL FIELD 100' CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL ' PUBLIC DOMESTIC WELL <br /> ' INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ` <br /> t Industrial Ix Cable Tool Dia. of Well Excavation '5 <br /> ,-Domestic/private Drilled Dia. of Well Casing 10" <br /> Domestic/public. -Driven PGau of Casing— <br /> Irrigation- - <br /> x. - �. x 101 <br /> _ Gravel Pack Depth of Grout Seal <br /> Cathodic Protection , ! Rotar . . . <br /> T <br /> y Type of Grout <br /> Disposal Other' Other Information <br /> Geophysical �� 'Surface :Seal Installed By: <br /> PUMP � ,� _.... � ,...._ ....., . <br /> INSTALLATION:f ION. Contractor <br /> Type ;of Pump-rj H.P., - I <br /> PUMP REPLACEMENT: 5 <br /> �Statd-Work Done T <br /> PUMP .REPAIR State Work Dode w <br /> i <br /> I <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure } <br /> I hereby agree_'to comply witheall laws and regulations of the San Joaquin Local Health Distract I <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 i <br /> information is true to the,bedt-of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION { <br /> PRIOR TO GROUTING ANDA FINAL !INSPECTION. <br /> SIGNED 11 <br /> TITLE Partner <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> 1 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION K ' ,V -VL4 PFASE 11.11YINAL INSPECTION _ <br /> INSPECTION BY -f DATE , INSPECTI B DATE / a ' <br /> =_Y26 <br /> _ j Ar- <br />• E H 14 2 6 Rev. 1-7 4� �--�•t iP.�li l / 1A W yr. v ��v.•�►�-.1 I c oar - <br />