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SAN JOAQUIN LOCAL_ HEALTH DISTRICT <br /> FO—W ICE USE: ' 1601 E. Hazelton Ave., Stockton, Calif. <br /> ,,. Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, 7Z,J1 5 u) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued S <br /> (Complete In Triplicate) <br /> Application is Aereby made to the San Joaquin Local Health District for a permit to eoostruet <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 5880 AVE. D-BET:^rEN UNION & AIRPORT WAY- CENSUS TRACT <br /> S Phone 415•-895934+8 <br /> Owner's Nam City' <br /> DOMINO <br /> Address 735 WILLIAMS ST. City SAN LEANDRO <br /> Contractor's Name 'Fi:,,N zNTNGS BROS.,- DRILLING CO. .INC. License # 2 081 Phone -54�5 <br /> ND LE AVE a MOD* <br /> TYPE OF WORE. (Check): NEW WELL /X-7 DEEPEN/-7 RECONDITION /-7 DESTRUCTION /-7 <br /> PUMR INSTALLATION / / PUMP REPAIR /—/—PUMP REPLACEMEO f7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK .N SEWER LINES PIT PRIVY , <br /> SEWAGE DISPOSAL FIELD _ CESSPOOL/SEEPAGE PIT OTHER C t( �r ' <br /> PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> IIiTENDED USE TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 11" <br /> X Domestic/private Drilled Dia. of Well Casing 6" pla stic N <br /> Domestic/public <br /> Driven Gauge of Casing 160 xall <br /> Irrigation _ Gravel Pack Depth of Grout Seal 50� <br /> Cathodic Protection X Rotary Type of Grout Bentonite - + <br /> Disposal Other Other Information Slab-byowner <br /> Geophysical Surface Seal Installed By: driller <br /> CAM i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUINP REPLAN: / / State Work Done <br /> v <br /> PUlHP °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 istrict <br /> and the State of California pertaining to or regulating well'construct . Witcal in FIFTEEN DAYS a <br /> after completion of my work on a new well, I will furnish the San Joaquin <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—FINAL INSPECTION. f <br /> SIGNED NNIN S B S . I INC. BY TITLE �-) <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> PHOS I <br /> _ FOR DEPARTMENT USE ONLY DATE �1"��// <br /> --2ir--7, <br /> APPLICATION ACCEPTED BY 4 _ <br /> ADDITIONAL COUNTS: <br /> PHASE II GROUT INSPECTION PHASE PECTION <br /> I I/FIN INS <br /> INSPECTION BY <br /> DATE ' INSPECTION BY -�' a -' ,. DATE <br /> LL <br />