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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR--'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. t <br /> Telephone: (209) 466-6781 J, <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMA' PERMIT Permit No. � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health district for a pezmit 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 1980 White Lane CENSUS TRACT <br /> f <br /> Owner's Name _ _ Veronica AugeTlo _ _ �. _ Phone <br /> Address 1980 White Lane Stockton Calif/-\95205 City ' <br /> Contractor's Name Purvia3nce DriT ers P.4.Box 64 Linden Calif. License # 24.010.7 Phone 931-4469 <br /> k f <br /> 95R36. <br /> �� � <br /> TYPE OF-WORK"(Check)": "NEW-WEL_ / `"DEEPEN��7—RECONDITION / DESTRUCTION__r7- <br /> _ _ <br /> PUMP INSTALLATION /x/ PUMP REPAIR /7 PUMP REPLACEMENT f7 <br /> Other / 7 <br /> DISTANCE TO NEAREST: SEPTIC TANK 200' SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 200' CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL IM! PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ` <br /> Industrial x Gable Tool Dia. of Well Excavation <br /> .L211 <br /> Domestic/private Drilled Dia, of Well Casing 120 <br /> Domestic/public Driven Gauge of Casing io <br /> X Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout' i <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed B : ; <br /> PUMP INSTALLATION: Contractor Purviance Drillers <br /> Type of Pump J Turbine H.P. 20 � ! <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP ,.REPAIR: _- / State.-work.Done <br /> ,.. . <br /> aS•TRUCTION _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 notify them before'putting..the.;well in-use.. The above <br /> information is true to the-best of my.knowledge and belief,. :iinTLL�CAi,I. FOR,A GROUT INSPECTION <br /> PRIOR TO GROUTING A FINAL INSPECTION:: <br /> SIGNED TITLE Partner s. <br /> (DRAW PLOT PLAN, 'ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I _ `1 - <br /> , P ` y"4 DATE } <br /> APPLICATION ACCEPTED BY �; 19 g <br /> ADDITIONAL COMMENTS: , <br /> PHASE I GROUT,INSPECTION PHA5E7-W- IFYNAL INSPECTION , <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1=74 1-74 2M <br />