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SAN JOAQUIN LOCAL HEALTH DISTRICT -- <br /> FOE OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Pe rmi No. 2 1: V2 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED l "Ov ate Issued Z O <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 20592 Ayers Avenue CENSUS TRACT <br /> Owner's Name Brook Bower Phone 838-3927 <br /> Address same City Escalon <br /> Contractors Lkense <br /> Contractor's Name ® ® ��� a License # �g®, Phone_ _5.2-9-2.020 ` <br /> .. I <br /> TYPE OF WORK (Check): NEW WELL/7 DEEPEN ' / RECONDITION /_/ DESTRUCTION <br /> ALREPAIR <br /> PUMP INSTLATION PUMP REPAIR '/ / PUMP REPLACEMENT A-7 <br /> Other / <br /> I <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 /> x 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 /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: J <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /g/ State Work Done Install 2 HP subm <br /> -PUMP-.REPAIR _„ .. / / .S-tia-te--Work-«Donee..rw <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth 1 <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 knowledg nd belief. I WILL CALL FOR A GROUT INSPECTION j <br /> PRIOR TO GRO NG AND A FIN INSP I N. _ j <br /> SIGNED TITLE <br /> y:(D1AR:PtOT PLAN ON RE FRSE SI ,.. <br /> b FOR DEPARTMENT USE ONLY <br /> PHASE I G --- I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIO P S I/FI NSPECTIOIJ <br /> INSPECTION BY DATE INSPECTION B ATE D <br /> E H 1426 376 <br /> Rev. 1-74 <br />