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Page 7 of 51 <br /> SAN SOARUIN LOCAI. HEALTH DISTRICT <br /> 1601 E. OppxeIten Ave., Stockton, CaILE- <br /> FOP, DFF3CE USE: TcicphoaA: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR pUNr PERMIT Dae Issued <br /> s <br /> • Date sssued / ✓•JG <br /> - THIS EERMlT EXPIRES 1 YEAR PROM RATE ISSUED <br /> (Co--plete In TrlDlicate) sxolt eo cane[rucC <br /> Appifeaaion is hereby a+ada to the San Joaquin Local Health Disirice for a pth <br /> his <br /> ouncy Ordlnwsa No`o 1862rk eana he Rules andTregulationstOfn the Sanis s7onryuinin p].acala NealthSDfls[rie n <br /> CENSUS TRACT <br /> SOS ADDRESS/LOCATION / <br /> Phase d.-x-e <br /> —0uner's Name LT. d•L - <br /> -.+� city R�E <br /> Address `3l1 "�"4•^- <br /> A/ . (+ 4icenee 4• Phone$f_��Yi1�v <br /> CaneraCtor'n Nath <br /> TYPE PP HORN (Che NEi%,.p�L 1-7 DEEPEN 17 RECONDITION I_i OESTRUCT10H 1_/ <br /> 0O•INSTALLATION 0 FUN' REPAIR lrule REPLACEMENT <br /> OthercO <br /> DISTANCE TO NEMMS''MSEPTIC TANK - SL9fER LLNE5 PIT PRIVY <br /> ..+'"- SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGN PIT OTHER <br /> l A c-+1 i PVA LIC DO"QS?'lC WELL <br /> »-RR7PER'TY LSgE.--PRIVATR ME5TIC wt1.LCONSTRDCTION SPECIFICATIONS (I <br /> L INTrAIDED.OSEgw+ T1TE O WELT, <br /> Industrla3�T93.-s'-.•! ��-Gatrl'e'Toal D£a. of Well Excavation <br /> ➢Dasa ClC/PDrilled Die. of Well Cnaing <br /> Doeastfc/ppvk c.1 = <br /> Driven Gauge of Casing <br /> ZrrfgatiOn+ Gravel Pack Depth of Grout Seal <br /> LCathodic Protection ®^ Rotary Type o€ Great <br /> Dibpaskl Othor other InfOrtlati0A t <br /> —Ceaphyafcel . . Sur£nce Sea3 Inetniled E _ <br /> J� <br /> L PUMP INSTALL moN: Contractor <br /> �• Type of Pump 7 <br /> PUMP REPS.ACEMEN1r State Work Done <br /> Y <br /> PUHI',REPAIR_ j. I-j state Work bona - <br /> .: i Approximate Depth <br /> O;STRUCTION OF WELL: Wall Diameter <br /> + Describe Macorial and Procedure <br /> I hereby agree to coaply with ali laud and ragala[io-ns of the Sam Smagvin Local Health District <br /> and the State of�Cal3forttla_percaiaing.;p�?r zwSula_ ting ce1P conacructlea. Within FIFTEEN DAYS <br /> after completion of my work nn a nevisjelly 73�-�uil-1 furnish rhe San .laaquin U'cal Health bo District <br /> WELI. DRILLERS'REPORT 6f [hd veil-add na E3'fy'"ihem hTfore puE�'ng CUe wa11 in use' 'Plfe above <br /> information in true to the heat of my knovlcdga and beliof. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING •D A FINALINSPECTION. TITLE <br /> SIGNED D_Rtw PLOT PLAN ON REVERSE SIDE <br /> - - FOR DEPARTTfENT llSE ONLY <br /> I <br /> PHASE 1 DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL OO`OffiNTS= P• S I 71 LINSPECTION <br /> PHASE II GROUT INSPECr1ON tNSPECTICN BY DATE i 7� <br /> INSPECTION By _ DATE <br /> . )/2011 <br />