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_ 3 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Fo"K;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. i <br /> Telephone: (209) 466-6781 <br /> Qr. APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Nox <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 Rubs and Regulations of the San -Joaquin Local Health District. <br /> zw <br /> JOB ADDRESS/LOCATION T CY BLVD & LINNE RDs CENSUS TRACT " <br /> Owner's Name MIKE AZPIETIA Phone�✓ r <br /> •I <br /> i <br /> Address -- 27766 CORRAL HOLLOW RD". „ - ..� City TRACY <br /> Contractor's Name HE NINGS BROS. DRILLING CO. INC . ` License #290813 Phone 522-1031 <br /> MO E TO <br /> i <br /> TYPE OF WORK (Check): NEW WELL /R7 DEEPEN/-7 RECONDITION /7 DESTRUCTION f7 <br /> PUMP INSTALLATION -/� Pump REPAIR -/� PUMP REPLACEMENT-- <br /> Other /% <br /> DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINES 10,of PIT PRIVY <br /> SEWAGE DISPOSAL FIELD QQ CESSPOOL/SEEPAGE PIT OTHER 41 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL, PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONS'T'RUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing 81, -S L <br /> Domestic/public Driven, ' Gauge of Casing 10 GA <br /> Irrigation Gravel Pack Depth of Grout Seal__ <br /> Cathodic Protection X Rotary Type of Grout Bent!�IjLte <br /> Disposal. Other Other Information .Slab-.by_owner <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION- Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: . <br /> State Work Done � •y ' <br /> + <br /> 'Obe /"JAM//at Un E'ccr Luella � .r� /l <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approxima e 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 reg',ul:ating"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. RV <br /> '. <br /> SIGNED ' <br /> (DRAW PLOT PLAN ON(--REVE14SE SIDE J <br /> FOR VEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEPTED BY DATE ' 16 <br /> ADDITIONAL COMMENTS; 8 p 6(J - <br /> PHASE II GROUT NSPECT • PHAS III FINAL I EaTION <br /> INSPECTION BY DATE / ' INSPECTION BY DATE <br />