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SAN JOAQUIN,LOCAL HEALTH DISTRICT <br /> FOfi OFFICE USE: .1601 E. Hazelt5n .Ave. , Stockton, Calif. <br /> Telephone: (209), 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 6- 3S6Cr) <br /> THIS.PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> - <br /> Application is hereby trade to the San Joaquin Local Health District for; a ,permit to construct <br /> and/or install the work herein described. Thi.s 'appllcation is made in compliance with Sah,Joaquir <br /> County,Ordinance No. ,1862 and the Rules' and Regulations of the San-'Joaquin Local Health District. <br /> 22 <br /> JOB ADDRESS/LOCATIONd & &A r irt� a CENSUS, TRACT <br /> �f <br /> Owner's Name J Machado <br /> Phone ' 82 -6605 <br />` Address <br /> 24q166. Mante a Rd. City' Manteca <br /> Contractor's NameHPUningg.. , : Drilling Ca. Inc. License # 2 0813hone : L22-1031 <br /> P500 W. le Rd. a Mod, <br /> TYPE OF WORK (Check): NEW WELL '/X7 DEEPEN 7 RECONDITION /7 DESTRUCTION f7 F VQ' <br /> PUMP INSTALLATION f_1 PUMP REPAIR/_7 PUMP REPLACEMENT <br /> Other L/ / <br />' ;DISTANCE TO NEAREST: SEPTICjTANK — SEWER LINES PIT PRIVY <br />;'. SEWAGE !DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER _ <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' - PUBLIC <br /> DEDDOMESTIC WELL ��71 <br /> INTEN . .USE TYPE OF WELL , CONSTRUCTION SPECIFICATIONS <br /> Industria] :Cable Tool -Dia., of Well Excavation <br /> Domestic/private I Drilled Dia. of Well Casing n <br /> Domestic <br /> /public Y. E Driven Gauge of Casing <br /> �g Irrigation 4X `.Gravel Pack Depth of Grout Seal <br /> Cathodic Protection X Rotary Type of 'Grout , <br /> Disposal I Other . Other Informationt <br /> Geophysical _ ^" Surface Seal Insta3leher <br /> : <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> B.P. <br /> 3 << <br /> PUMP REPLACEMENT: .: "C7 :State Work Done <br /> PUMP .REPAIR:, /7 `State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> ' Describe Material and Procedure Approximate Depth i <br /> I hereby agree to comply with ,!all laws and regulations of the San Joaquin Local Health District <br /> slid the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work oii a new well, I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPORT of the .well and notify them before putting.the..well in-use... The above <br /> information is true to the of. my knowledge and belief. I WILL CALL FOR A -GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED 0 'INC'. BY TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE SEC. <br /> PHA�I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY / <br /> ADDITIONAL CODA MS: DATE: y- 3 `-7 G <br /> PHASE I GROUT INSPECTION PEASI PIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426Revd 4. ._ ._ . <br />