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'SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. - Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, �7`/31--P <br /> ' - <br /> • - THIS7'7PERMIT EXPIRES� I �YEAR FROM DATE ISSUED Date Issued ��=�] <br /> I (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 Opl:ication is made in compliance with San Joaquink <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> Y <br /> JOB ADDRESS/LOCATION 700' East Wall Road & 1 Mile North I alHut�,T3'"jf en; CENSUS TRACT 0'? 3[d <br /> Owner's Name Marion Go aPhone <br /> Address. ----- � 4 4. � N--�94 -N�wJackzTone Goad,-Stckotz�-Gad is _ ;2p t:�- ..=:.- _City <br /> ..�` ;n <br /> i- Contractor's Name Furviance Driller st Box bl, Linden Cal-if.9523(License # 2.4.0107 Phone 9�440 <br /> i <br /> TYPEwOF WORK (.Check),:,NEW WELL/Z. DEEP,ENS/ �_RECONDItION�,./ DES�TRUCTION�/� <br /> PUMP INSTALLATION-/x/ PITMP�,REPAIR % /- PUMP-REPL-ACEMENT-- <br /> Other / / t <br /> DISTANCE TO NEAREST: SEPTIC TANK 5Q01 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD .CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WEL ' PUBLIC-DOME-ST-1-C WELL m <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial i x Cable Tool 'Dia. of Well Excavation 129' <br /> Domestic <br /> /Private I Drilled Dia, of Well Casing '1211 � <br /> EDOMestic/public Driven '' Gauge of Casing 10 <br /> ri tion GravelPack.` �r"Deptd-j.of Grout Seal odic Protection Rotary - -1Type of Groutsposal Other Other Information ' -H c <br /> :Geophysical <br /> Surface Seal Installed B b <br /> f % <br /> 77 <br /> PUMP INSTALLATION: Contractor PurviancetD- <br /> Type-of-Putng Turbine ' - .H:P. _30 i <br /> PUMP REPLACEMENT: ' / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br />+--^a......w.v..� T..._� --_`•-•ne.� . � •1- rte. __ <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply withtall 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 /> PRIOR TO GROUTING AN A FINALiINSPECTION. <br /> SIGNED TITLE Partner <br /> ,, DRAW P0T PLAN 'ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I A <br /> APPLICATION ACCEPTED BY DATE —2, <br /> ADDITIONAL COMMENTS; <br /> PHASE Il G 0 SPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY <br /> DATE INSPECTION,BY DATE <br /> 4 1426 Rev. 1--74 376 2M <br />