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G SAN JOAQUIN LOCAL HEALTH <br /> FOR OFFICE USE:FOR <br /> 1601 E. Hazelton Ave:, Stockton, Calif. <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 1 YEAR MOM 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 ani the-Rules- and Regulations of the San 'Joaquin Local Health District. <br /> Jas ADDRESS/LOCATION <br /> 13 .63 N.Thorton Rd. ,West Side 201 - <br /> -� { CENSUS TRACT <br /> Owner's Name State of Cali og/9� <br /> 8-� � - <br /> fornia,Dept.Transportation Phon� -7563 <br /> Address <br /> P,O.Box 20 .8, Stockton, Ca13.fornia City . Stockton <br /> Contractor'e Name Piombo Corporation L cense # 230844 Phone209/369-1091 <br /> TYPE OF WORK (Check): NEW WELL DEEPEN '/? RECONDITION f-7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR -7 PUMP REPLACEMENT- r7 <br /> Other — <br /> k <br /> DISTANCE TO NEAREST:- SEPTIC TANK - SEWER LINES • PIT PRIVY <br /> SEWAGE 'DISP05AL FIELD CESSPOOL/SEEPAGE PTT -- 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 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Dom6stic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal � `y � <br /> Cathodic Pr_otect_i_ on Rotary Type of Grout <br /> Disposal Other Other Information ' <br /> Geophysical -' Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor i <br /> Type -of Pump H.P. <br /> "PUMP REPLACEMENT <br /> L/ State Work Done w <br /> PUNfP '.REPAIR: <br /> State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 16" y ' <br /> Approximate Depth 60 t., / <br /> Describe Material and Procedure Sated to 0 <br /> 0" below 5 5 sack concre e o <br /> ground level. f <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 puttingthe-well. in.use... .The above <br /> information is tr to the-best of my..kno ledge and belief. I WILL CALL FOR A 'GROTINSPECTION <br /> PRIOR TO GROUTIN D A FINAL INSPE UT <br /> SIGNED i TITLE <br /> {DRAW P T ON REVERSE SIDE) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APP' LIGATION ACCEPTED BY ' -• -. <br /> ADDITIONAL. COMMENTS: DATE��� <br /> PHASE IX. GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION. BY DATE INSPECTION BY DATE <br /> E H 1426'` . Rev. 1-74 -- <br />