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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO" <br /> !OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. , '" ■'r <br /> Telephone: (209) 466-6781 ��rAr•rGD <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7V-, y <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued�j2 --2Z-.?q <br /> Application is hereby made to the San (Joaquin Local HComplete in ealth 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 2.0350 Allen Road <br /> CENSUS TRACT <br /> Owner's Name Arthur Azevedo <br /> Phone 599-4477 <br /> Address Same <br /> City Rip n. <br /> Contractor's Name T.D. Sutton and Son License # 279010 Phone838-2207 <br /> TYPE OF WORK (Check) .- NEW *WELL -/ `7�-�EEPENA I? (RECONDITION /=7 DESTRUCTION _� <br /> PUMP INSTALLATION /—/ PUMP REPAIR �_P _REP�OEMENT.._ <br /> Other /X/ Remove old urs from oZd well and i0s t all—in new well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY •- <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PITT_^ � OTHER � I <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE ,TYPE OF WELL ? CONSTRUCTION SPECIFICATIONS © i <br /> Indust rial Cable Tool Dia. of Well Excavatio w <br /> - Domestic/private Drilled Dia. of Well Casing <br /> Domestic/publicDriven� g <br /> �_ .,.,._ �-,�.Gau e."o£-Casing� <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> ` Cathodic Protection - --- Rotary Type of Grout <br /> Disposal 3 Other ' fthex_Inf_ormation <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. r T <br /> PUMP REPLACEMENT: /7 State Work Done G � ' <br /> 'PUMP.REPAIRi "-. � l7—State Work Done <br /> ES:TRUCTION OF WELL: Well Diameter (TO BE DONE BY OWER)}T Agpro�cimatie, Depth <br /> Describe Material and Procedure: '- " �`ti <br /> -y <br /> Vi �ll <br /> I hereby agree to comply with all laws and regulationd. of the San Joaquin Local Health District @ <br /> and the State of California pertaining to or regufat,iig 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 GROUTING ANDA INAL INSPECTION. � <br /> SIGNED i TITLE Partner <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .d7�? DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY / DATE <br /> ' E H 1426 Rev. 1-74 1-74 2M <br />