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41, SAN JOAQUEN LO AL HEALTH. DISTRICT ► ' <br /> FOErOFFICE USE: 601 E. Hazelton Ave. , Stockton, Calif. <br /> t Telephone: (209) 466-6781 <br /> k APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. L) <br /> THIS PERMIT EXPIRES 1 YEAR FROM 'DATE ISSUED Date Issued 1 �> <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 /> JOB ADDRESS/LOCATION .7222 E. FRENCH CAMP RD. CENSUS TRACT <br /> Owner's Name MARVIN ZWART Phone 806 <br /> Address, 2 163 S. JACKTONE City RIPON CALIF. <br /> Contractor's Name License # 29081-1 Phone 5122-10.31 <br /> NNIN S BR • i <br /> TYPE OF WORK (Check) : ANEW WELL 'X1 DEEPEN/ / RECONDITION / / DESTRUCTION /_7 <br /> PUMP ZNSTALLATTON / / 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 24't <br /> Domestic/private, X Drilled Dia. of Well Casing 1 rr <br /> Domestic/public i Driven Gauge of Casing <br /> �3 Irrigation 11 X ' Gravel-Pack-- , Depth-of Grout Seal x <br /> Cathodic Protection X Rotary Type of .Grout l Nwt +► �'""� <br /> Disposal Other Other Information 1,;Lnb by owner <br /> Geophysical j , Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> . ,Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP-.REPAIR:__... }: /_.-/Stat e„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 'Calii,ornia 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 IN <br /> PRIOR TO GROUTING AND .W FINAL INSPECTION. <br /> SIGNED' ' I TITL Zl J <br /> .11. „10 W: L TPLAN 'ON RE FRSE SI j` <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> � � , <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: � ILA JAAEj� gel <br /> P SEI ! GROUT ftNgPECITION f PHASE IIIIVINAL SSPECTION <br /> INSPECTION BY /—17— 7-7 FECTION BY DATE —%L <br /> E H 14R v. 1=74 f.'/ U .�l i �va G , .� ✓. <br />