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SAN JOAQUIN LOCAL ;HEALTH DISTRICT <br /> FOR!OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> , . 'Telephone; (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. S__A _ rl <br /> rt THIS PERMIT EXPIRES 1 YEAR :FROM DATE ISSUED Date Issued 915 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health Disttiet for a pexmit to construe <br /> anti/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 anis the Rules and Regulations of the San Joaquin Local health District. <br /> JOB ADDRESS/LOCATION 0 6t <br /> om"nrthtntsasall CENSUS TRACT <br /> Owner's Name camp/Asparagus shed <br /> Phone . .L5-3_654 <br /> Address P o'. , . t City Tracy <br /> Contractor's Name -Henn 133 <br /> F w. _ �� a <br /> g os Dri i 1 i . g Q01'. Ines License # 22081 Phone __522-10 1 <br /> ° --Modesto <br /> TYPE OF WORK Check): NEW WELL /K� D <br /> ( � EEPEN '/ 7 RECONDITION /� DESTRUCTION /� ; <br /> PUMP INSTALLATION / / PUMP REPAIR /� PUMP REPLACEMENT / f <br /> DISTANCE TO NEAREST: SEPTIC 'TANK SEWER LINES PIT PRIVY <br /> . SEWAGE7ISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ;PROPERTY LINE - PRIVATE DOMESTIC WELT. . IPUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ; Cable Tool Dia. fof Well Excavation 2" <br /> Domijstic/private Drilled dia. Sof Well Casing ft <br /> Domestic/public Driven Gauge of Casing <br /> Irri'gajion a Gravel Pack Depth of Grout Seal 1 <br /> Cathodic Protection,,--t..X .Rotary Type of Grout` <br /> _.Rentnni i P <br /> —DisposalGeophysical' Other Other 'Information <br /> Surface Seal Installed B e ` <br /> PUMP INSTALLATION �p'—Coni '' lC <br /> tactor <br /> i Type of PumpP <br /> H• • 1 <br /> PUMP REPLACEMENT: ` <br /> /-=% S Cate Work Done ©P of c r e T R <br /> Gfi o — <br /> PUMP !REPAIR: ttt /7 Sate work- Done <br /> ES;TRUCTION OF WELD:: "'Well'D ame ter Approximate Depth <br /> Describe Material and Procedure 1�_� <br /> I hereby agree to comply with- laws and regulations of the San Joaquin Local Health Diand the State o€ California pertaining to or regulating well construction. Within FIFTEEN DAS <br /> after completion o my work on a new well, I will furnish the ..San Joaquin Local Health District a <br /> WELT, DRILLERS REPORT of the well and notify them before putting..the- well in use.. The above <br /> information'is txue to 'the beat of my.knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUTING':AND A FINALS INSPECTION. <br /> SIGNED G i TITLE <br /> 4_1 <br /> 110 $; (DRAW PLOT PLAN,-ON REVERSE SIDS <br /> PHASE I !% EQR 3 D'' MENT USE ONLY <br /> APPLICATION ACCEPTEDIBY; <br /> ADDITjONAL'--COMMENTS: I DATE <br /> P SII ROUT INSPECT40N P I FINAL INSPECTION <br /> INSPECTION BY DATE 'TI <br /> DATE <br /> 4 <br /> E H 1426 Rev. 1-74 <br />