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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 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 a � ; <br /> qM3 S _ (Complete In Triplicate) f ,,Ox) : 2—V-?--12,0 17 <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 th Rules and Regula ions f the San Jo quin Local Health District. j <br /> N /rN LQ G-1aL, , 4 �- dmf ,�I�l7��� <br /> JOB ADDRESS/LOCATION Escalo CENSUS TRACT <br />'f Owner's Name John Van Ruler Phone .529-9022 <br /> s <br /> Address City Fsna.lnn <br /> Contractor's Name atajai sl aus.Bjmp & Manh1ne= CnrMra.+.i on License. # 5 Phone <br />( TYPE OF'WORK (Check). -NEW`-WELL- DEEPEN /_.../L�-RECONDITION_f/7 ESTRUGTION-/�4.- <br /> PUMP INSTALLATION /x/ PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br />+' Domestic/public Driven Gauge of Casing <br /> x Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection i Rotary Type of Grout - <br /> _Disposal Other Other Information <br /> Geo hysical Surface Seal Installed BY: <br /> PUMA' INSTALLATION: Contractor a±anj&ja <br /> Type of Pump H.P. _._60 - <br /> f PUMP RE EMENT: / / State Work Done - <br /> PUMP ..REPAIR: _._ _- s..,..�//, �State-Work .Done <br /> DESTRUCTION 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 anew 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 TOG UTING AND INSPECTION. This is ready for inspection ; <br /> SIGNED TITLE ,Z41 <br /> ;Ik <br /> DRAW PLOT PLAN 'ON REVERSE SIDE) {" <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I, <br /> APPLICATION ACCEPTED'BY ; r DATE Z7& <br /> ADDITIONAL COMMENTS: �• <br /> PHASE II GROUT INSPECTION PHASE /FINAL INSPECT- N <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> . H 4.26,,-Rev. _1774 <br />