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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOH 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 <br /> (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 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 /> 30B ADDRESS/LOCATION 2/ZtLFi1.e North Bury 1, at end of Van Allen Road CENSUS TRACT /e3- Z&—CaP' <br /> Owner's Name R J Dondero Phone <br /> Address 16299 E. Hwy 260 Tjnden, Calif. City <br /> Contractor's Name urs►ianoe. aril" er ,l?,O.Bflx ,T, <br /> _64iruien, _Ca't if. License # 240707 Phone 9.31- <br /> ---- - --- -- <br /> - - - 95296 <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN RECONDITION /_j DESTRUCTION /-7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT /- <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK1/4_ i WER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD Jai CESSPOOL/SEEPAGE PIT OTHER (n <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 EX�atjDZ 16" _ <br /> Domestic/private Drilled Dia. of Well Casing Int_ 1J." 1,'1 nor <br /> Domestic/public Driven Gauge of Casing <br /> X Irrigation Gravel Pack Depth of Grout Seal Al <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information_ <br /> Geophysical Surface Seal Installed <br /> h <br /> PUMP INSTALLATION: Contractor r{ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / 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 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 GROUTIN D FINAL INSPECTION. <br /> SIGNED TITLE <br /> ;DRAW POT PLAN ON REVERSE SIDE) <br /> FOR IEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ,..---41DATE <br /> ADDITIONAL COMMENTS: Vj <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br /> 3/76 2M <br />