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�j OF <br /> FOF� ?4f JOAQUIN LOCAL HEALTH DISTRIC <br /> ; FICE USE: 160'-. . Hazelton Ave. , Stockton, Cale <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 4 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ��-�� <br /> Date Issued 7-7 <br /> (Complete In Triplicate) <br /> Ai)plichtion is hereby made to the San Joaquin Local Health District far aermit <br /> uto co <br /> nd/ <br /> Caor.. install the work herein described. This application is made in compliance withnSan uJ'oaq uil <br /> untyOrdinance Na. 1862 and the Rules and Regulati s of the San .Iaagnin Local Health District. <br /> JOB ADDRESS/LOCATIO l �- .0 !/v ct. <br /> Owner's Name Lr!:eI ins iii <br /> P ne <br /> Address ! 7990 E. -=:: i0rl 1%oau, .inden, G!�'.if 95236 <br /> !I City _ <br /> Contractor`s Name PurNiiannceri"-_rsyl .-G.' ox `6 �7,inde.1�Oa j.f, <br /> 1. License # 240107 Phone f31-[,.1`..68 > <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN -,&-T RECONDITION <br /> PUMP INSTALLATION / PUMP REPAIR -7 PUMpEREPLACEMEN /7 <br /> Other E7 <br /> DISTANCE TO NEAREST: SEPTIC TANK 7515' SEWER LINES <br /> PIT PRIVY <br /> SEWAGE DISPOSAL FIELD '75' CESSPOOL/SEEPAGE PIT <br /> PROPERTY LINE 'RIVATE Dpi9ESTIC WELL PUBLIC <br /> - OTHER <br /> INTENDED USE TYPE OF WELL C DOMESTIC WELL <br /> k Industrial - CONSTRUCTION SPECIFICATIONS <br /> x Cable Tool Dia. of Well Excavation JEEX .St:it'] " ;e7 <br /> Domestic/private Drilled <br /> Domestic/public - Dia• of Well Casing Ins v0' 0 6 5 {>" �.Inez, <br /> Driven Gauge of Casing 12 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection -.. 'Rotary <br /> Disposal Type of Grout --S <br /> Other Other Information -Z <br /> Geophysical -i1 <br /> 4 <br /> ,; Surface Seal Installed "By:' a <br /> PUMP INSTALLATION: Contractor t`j1 <br /> Type of Pump <br /> _ H.P. <br />'UMP REPLACEMENT: <br /> / State Work DoneJ.Le s'c:��1 CLISzOr er 2 r pt�tnp <br />'UMP .REpAIR: / / . State Work Done . . . . <br />�ESITRUCTmION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> it <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br />.nd.� the State of California pertaining to or regulating well "construction. Within FIFTEEN DAYS <br /> fter co`'il.etion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> MP <br />'ELL DRILLERS REPORT of the well and notify them before putting the -well- in use The above <br /> nformation is true to the--best .af. my.knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> 1IOR TOI�GROUTING ANDA FINAL INSPECTION. <br /> IGNED <br /> flTITLE Partner <br /> y <br /> " (DRAW PLOT PLAN ON REVERSE SIDE <br /> RASE I „ FOR DEPARTMENT USE ONLY <br /> pPLICATION ACCEPTED BY <br />)DITIONAL COMMENTS: DATE <br /> EEy.. PHASE II GROUT INSPECTION <br /> 4SPECTION BYPHA ItFINAL IINAL INSPECTION <br /> DATE INSPECTION BY DATE Lam/ <br /> F. H T 49F, nom,. z-'7,F. <br />