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SAN JOAQUIN LOCAL 'REALTH DISTRICT <br /> FO$;OFFTCE USE: 1601 E. Hazelton Ave, , Stockton, Calif. <br /> Telephone: {209) 466-67$1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S-z1 9/&J <br /> ,�, THIS 'PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> q 7,>r;_j-,^..Igj- - Date Issued is-/-7� <br /> Application is hereby made to the San(JoaComquin Loallete In rDealth Di <br />� and/or install the work herein described. This application isDistrict <br /> incompliancewithSanJoa uin <br /> for <br /> tconstruct <br /> . County Ordinance No, 1852 and the Rules and Regulations of the San -Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 1501W.6 f N.Thorton Rd. ,300'S of Hwy. 12 <br /> 1 CENSUS TRACT <br /> Owner's Name State of Calforni a,Dept.Transportation <br /> � Phone , 209/948-7563. <br /> Address P.0.Box 2048 Stockton, California <br /> City ,Stockton <br /> Contractor's Name Piombo Corporation License #, 230844 2D <br /> Phone 9/369-1091 <br /> Ir TYPE OF WORK (Check) : NEW WELL/� DEEPEN '/_? RECONDITION <br /> PUMP INSTALLATION / / PUMP REPAIRL-7—Pump EREPLACIEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINEPIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ OTHER f <br /> PROPERTf LINE - PRIVATE DOMESTIC <br /> INTWELL" PUBLIC DOMESTIC WELL f <br /> ENDED USE 'YPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> _ i Cable Tool Dia. of Well Excavation <br /> Domestic/private i� Drilled Dia. of Well Geeing \� <br /> _ Domestic/public Driven i <br /> Irrigation `� Gauge of Casing <br /> Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 1 Rotary Type of Grout <br /> Disposal 1 Other Other Information <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. I <br /> PUMP REPLACEMENT: 1 <br /> / / State Work Done <br /> PUMP .REPAIR: j! / State Work Dome <br /> DESTRUCTION OF WELL: Well DiI meter loll 201 <br /> Describe Material and -Procedure Approximate Depth <br /> sack concrct'e mix to <br /> 4I hereby agree to comply with allnla sbelow and g regulationsorthe San <br /> Joaquin <br /> and the State of California pertaining to or regulating well "construction.L ocal Withinalth FIFTEENtrict 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 rue to the.best ,of kn wledge and belief. I WILL CALL FOR A 'GROUP INSPECTION <br />?RIOR TO GR G AND A FINAL CT IO <br /> SIGNED TITLE I <br /> W PLOT PLAN ON REVERSE SIDE <br /> PHASE ,T FOR DEPARTMENT USE ONLY <br />!1'P�A 1ON ACCEPTED BY v <br /> f <br /> 4DDITIONAL COMMENTS: j DATE <br /> PHASE II GROUT[` INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY - DATE iNSPEGTION BY DATE Z <br /> �I <br /> E H 1426 Rev. 1-74 r' _ <br />