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JOAQUIN LOCAL HEALTH DISTRI <br />oFO11, 16A. Hazelton Ave., Stockton, Calif. <br />Telephone: (209) 466-6781 <br />APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <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 Rules and Regulations of the San Joaquin Local Health District. <br />'Auistln Road Disposal Site, Austin Road between Arch <br />JOB ADDRESS/LOCATION 7E.MDBh_ CENSUS TRACT <br />Owner's Name Forward, Inc. Phone(209)466-5192 'W44k <br />low; <br />Address P.O. Box 6336, Stockton, California, 95206 City <br />Calif. Registered Geolo 'st <br />Contractor's Name Beta Associates License # j5 3 Phone 295z7483 <br />TYPE OF WORK (Check): NEW WELL DEEPEN RECONDITION DESTRUCTION /-7 <br />PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT <br />Other ITI 3 -Monitoring Wells <br />DISTANCE TO NEAREST: SEPTIC TANK 1000 ft.SEWER LINES N/A PIT PRIVY N/A <br />SEWAGE DISPOSAL FIELD N/A CESSPOOL/SEEPAGE PIT N/A OTHER <br />PROPERTY LINE - PRIVATE DOMESTIC WELL LQ01 PUBLIC DOMESTIC WELL <br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br />Industrial Cable Tool Dia. of Well Excavation 9 in,ch-Q5-- <br />Domestic/private X Drilled Dia. of Well Casing 4 4 inches <br />Domestic/public Driven Gauge of Casing —Schedule 40 - EYE <br />Irrigation X Gravel Pack Depth of Grout Seal 201 <br />Cathodic Protection Rotary Type of Grout Neat Cement <br />Disposal X Other E!j_QtL_ Other Information Well #1-80' deep/#2_& 3-100' <br />Geophysical Auger Surface Seal Installed By: deep <br />PUMP INSTALLATION: <br />PUMP REPLACEMENT: <br />DESTRUCTION OF WELL: <br />Contractor <br />Type of Pump <br />State Work Done <br />State Work Done <br />Well Diameter <br />Describe Material and Procedure <br />H.P. <br />Approximate Depth _ _ <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 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 g.&QUTIN9 AND'A FINAL INSEWTIO W.' <br />SIGNED TITLE President Beta Associates <br />DW PLOT REVERSE SIDE) <br />IZA <br />FOR DEPARTMENT USE ONLY <br />PHASE I <br />APPLICATION ACCEPTED BY DATE <br />ADDITIONAL COMMENTS: <br />PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br />INSPECTION BY DATE INSPECTION BY DATE <br />2M <br />E H 1426 Rev. -I-74 <br />