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f SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOR OFFICE USE: 1601 E. HazeltonCAve. Stockton, 'Calif'. s <br /> Telephone: ".=-(209) ,46'6"6781 <br /> PLICATION FOR WELL CONSTRUCTION- OR- PUMP PERMIT Permit. No. 11 <br /> THIS PERMIT.�EXPIRES }1`.-YEAR-fFROM=DATE -ISSUED Date Issued <br /> r.::o (C6mplete. In=Trip'J.icite)' <br /> Application.�is herby7made"to the+Sari iJoaquin-'�Locala Health- District _f or Fa permit `to construct <br /> and/or install the work herein described. This ;application?is 'made 'in compliance with 'San Joaquin <br /> County -Ordinance ;No.xd862rand`.the 'Rules 'and!%Regulati.ons 'of `the .Sari Joaquin Locale Health. District. <br /> .5,"_.. st... �'}£sir'`.. ,t PE s;� ili3:=...5:!•. e. •i� ..1 ' <br />--JOB ADDRESS/LOCATION 1 58o8�E _ H l wa �� + CENSUS TRACT 5' <br /> .'fid� '`' 3'X� s?�i.�-S'1 '�A),: -$°.` t ,��.,'�.p 'I•'g' ,fa � Lit: „�3.,;e. 4 i �it.4 z Y1 + ..: 's � ..- <br /> - '. 70 �T <br /> Owner',s:NameOtlo :a _r.xen.rt-AZ'evedo z' �,t , r :► e. . s: 'i Phone; a ! ' <br /> Address f same , City Ripon: <br /> - 37 5'7 <br /> 0 <br /> Contractor's Name John Panero License # 120724 Phone886-5400 <br /> TYPE OF WORK (Check) : NEW WELL /t/ DEEPEN '/ / RECONDITION I-T DESTRUCTION /-7PUMP INSTLATION '/ I PUMP REPAIR / I PUMP REPLACEMENT I? <br /> AL <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC DANK 88 SEWER LINES _ PIT PRIVY <br /> t SEWAGE !DISPOSAL.FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial:, x Cable Tool Dia. of Well Excavation 1 2 conductor. <br /> X ` Domestic/private Drilled � T Dia: of Well Casing � T oQ <br /> Domestic/public Driven Gauge of Casing X12 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of .Grout _ cement <br /> Other Other Information <br /> = PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. m QC <br /> i <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> .DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I herre y agree to comply with laws and regulations f he 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 knowledge and belief. <br /> i <br /> f SIGNED TITLE . <br /> ` (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> ! PHASE I DATE <br /> APPLICATION ACCEPTED BY ' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT ;INSPECTION P1W.E,4II/FINAL INSPECTION <br /> INSPECTION BY INSPECTION BY DATE — <br /> CALL FOR._A GROUT INSPECTION•.PRIOR_TO GROUTING AND FINAL INSPECTION. 4172 <br /> E H 1426 1M <br />