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�� _ <br /> .w ��SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F FICE USE: 1601. E.' Hazelton Ave. , Stockton, Calif., <br /> 71 Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CORSTRUCTION.OR PUMP PERMIT Permit No. Z �5�k� <br /> THIS PERMIT EXPIRES 1 YEAR FROM± DATE:1ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permitto canitrict <br /> and/or .install the itork herein described. This application is :made., in compli.anc.e with San Joaquin <br /> County Ordinance'No 1862' and the Rules and Regulations of the San -Joaquin Loca]:..Health .District. <br /> JOB ADDRESS/LOCATION 15421 Santgp.. Rd.,�_jmi East of N.Ri on Rd.= CENSUS TRACT <br /> north side <br /> Owner's Dame Walter Anderegg Phone 408-353-1821+ <br /> j ,Address �+ 0 Miller Hill Rd. City `Los Gatos <br /> a <br /> Contractor's Name B o Erillin Co. Tne. License # 290813 Phone 522--1031 <br /> 00 W. Rumble Rd.-3Mod <br /> TYPE OF WORK (Check): NEW WELL -117 DEEPEN/7 T RECONDITION / DESTRUCTION f <br /> PUMP INSTALLATION I J PUMP REPAIR /7 PUMP EMEN <br /> REPLACT f7 ` <br /> Other / <br /> 'DISTANCE TO NEAREST: SEPTIC TANR&tp.,_X_,SEWER LINES PIT PRIVX_;j P_=_Z_ ,gp._,300( j <br /> V-4 SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER a),PZ4A&_Vp i <br /> n. <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMES TIC,WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. .of Wel Excavation -- <br /> ': Domestic/private Drilled Dia. of Well— Casing 1t <br /> Domestic/public Driven Gauge of Casing �,. <br /> e Irrigation Gravel Pack Depth of Grout Sear 501. <br /> _ Cathodic Protection' .1 ^ Rotary Type of Grout. , b ent onite. _ <br /> Disposal Other Other Information 'Zlab— y owner <br /> Geophysical Surface Seal Installed 'B : e <br /> (_UmP INSTALLATION: Contractor <br /> Type ,of Pump H.P. <br /> PUMP REPLACEMENT: L/ State Work Done - <br /> -State <br /> one State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth _ <br /> Describe Material and Procedure <br /> I hereby agree a to with all laws and regulations of the 'San Joaquin Local Health District <br /> comply p Y <br /> an& 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 theiSan Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting•. the..well. in.use.... .The above <br /> 4 information is true to- the-best.of. my.-knowledge and belief. . I WILL .CALL FOR':A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED 0 DRILLING CO. BY TITLE SEC'. <br /> kI� DRAW PLOT PLAN•ON REVERSE SIDE <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BY Vf. DATE <br /> ' ADDITIONAL COMMENTS: <br /> PHASE II GROUT <br /> IJP INSPECTION PHA I AL INSPESC <br /> TI N <br /> INS <br /> ITESINSPECTION DATE <br /> //J r E y <br />