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SAN JOAQUIN 'LOCAeREALTH DISTRICT <br /> FOA?OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. TS-" �_34� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 15400 Summerhome Drive CENSUS TRACT <br /> Owner's Name Gomes hone 239-2272 <br /> 7> <br /> Address City <br /> ManfPCrg <br /> Contractor's NameRraq _ License # 29Q81 Phone 522-1011- <br /> ===M=2==____= 2500 W. Rumble Rd. , Ido este _ <br /> TYPE OF WORK (Check): NEW WELL &"V RECONDITION /7 DESTRUCTION /_ <br /> PUMP INSTMATION /—/ PUMP REPAIR /7 PUMP REPLACEMENT 1 `A <br /> �A <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK 100 ' SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 4E <br /> x,,t' Domestic/private Drilled Dia. of Well Casing LS-1-0 <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protectiony Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed ll d By .. . "� <br /> PUMP INSTALLATION: Contractor A & B Electric <br /> Type" of Pump H.P. <br /> PUMP REPLACEMENT: ET State Work Done <br /> PUMP 'REPAIR: /_7 State Work Done <br /> ES•TRUCTION OF WELL: Well Diameter Approximate Depth <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 knowledge and belief. I WILL CALL FOR A GROUT INSPECTION � <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNEDDrilling Co TITLE o <br /> DRAW PL T <br /> #�.fj FOR D 'LAN ON REVERSE SIDE <br /> EPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: �-- <br /> PHASE izGROUT INSPECTION P SEI FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br /> 1-74 2M <br />