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f� } <br /> v SAN JOAQUIN.LOCAL HEALTH DISTRICT <br /> 051r, FFICE USE» ' 'f 1601 E. Hazelton Ave. , Stockton, Calif. r <br /> I/ Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES I YEAR FROM DATE 'ISSUED Date Issued <br /> (gid l �- ..� raj• (Complete In Triplicate) fo3 -- zno-t( <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> sand/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/LOCATION1001 West of Jack Tone Rds mile.North Coppero' gMENSUS TRACT <br /> Owner's Name Dan"Brandstad Phone <br /> Address1 .090 E. Baker Road Stockton, C lif. 95205 Cit.Y . <br /> i L'.inden Calif. License # 240107 Phone.,_- 931-41+68 <br /> Contractor's Name Purv�i.ance ,Dri�_lers Box 61,., ' . <br /> TYPE OF WORK (Check): NEW WELL -/7 DEEPEN /g? RECONDITION )*7 DESTRUCTION <br /> PUMP INSTALLATION / PUMP REPAIR I� PUMP REPT.ACEMENT FT <br /> r. Other L <br /> F DISTANCE TO NEAREST: SEPTIC TANK 600LI , SEWER LINES PIT PRIVY <br /> SEWAGEIDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> k PROPERTY LINE - PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL <br /> INTENDED USETYPE OF WELL 1 CONSTRUCTION SPECIFICATIONS <br /> Industrial <br /> . ,,j x - 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 ► '• Rotary Ty4e.__of`-Grout <br /> Disposal t Other Other Information '1Q:=x TO Ra cod_. �nsy be Inst• <br /> Geophysical Surface Seal Installed By: <br /> - f <br /> PUMP INSTALLATION: Contractor Purviance.Dri1_1ers <br /> 1 Type'`':of Puiap _ Tu bim H.P. - 7 C <br /> PUMP REPLACEMENT: /g/ ).State Work Dane <br /> PIMP :REPAIR: / / !.!State Work Done 1 <br /> b llES•TRUCTION OF WELL: Well',Diameter Approximate Depth <br /> Describe Material and- Procddure <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/flrnish 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 /> I information is true to the-best -of my.-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING * A FINAL I SPECTION. <br /> SIGNED TITLE c ii�0lel/ <br /> (DRAW PLOT PLAN pN REVERSE SIDE <br /> "I FOR DEP AR T USE ONLY <br /> PHASE I l '' z - - _--` -�- T $ - ��`�%�� <br /> �c— <br /> APPLICATIONrACCEPTED•BY - <br /> ADDITIONAL COMMENTS: 7m <br /> PHASE II GROUT INS ECTION PAA INSPECTION <br /> INSPECTION BY t DATE INSPECT-ION BY DATE <br /> �ZZ5 2M <br /> V. H IATA Rav_ 1-74 �. <br />