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4V <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR,.OFFICE USE: 1601 .E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) ,466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7z <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued - <� 2 <br /> 1 (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 /> JOB ADDRESS AOCATION 2284 a. Inlanq Drive <br /> CENSUS TRACT <br /> .Own'er's Dame Neal Collins Phone ' <br /> Address 2284 S. Inland Drive Stockton <br /> City i <br />•Contractor's Name We Ge Noack Inca -� License #200 794 Phone 948 8817 <br /> TYPE OF WORK (Check): NEW,`WELL f*7 DEEPEN " - ��- _ ~ <br /> 17 RECONDITION �7 DESTRUCTION / f <br /> PUMP INSTALLATION/_7 PUMP REPAIR:/7 PUMP REPLACEMENT— <br /> Other <br /> DISTANCE TO NEAREST:' SEPTIC TANK 6`2 ft I --- <br /> r SEWER' LINES 70" ft • PIT PRIVY rt- <br /> SHWAGE„DISP.OSAL -YIELD , CESSPOOL/SEEPAGE PIT OTHER i �y <br /> PROPERTY LINE -- PRIVATE DOMESTIC-WELL ''PUBLIC DOMESTIC WELL ` <br /> Industrial TYPE OF WELL � ” CONSTRUCTION SPECIFICATIONS <br /> Industrial :: Cable Tool , D`ia of-Well Excavation ' 0 inc <br /> * Domestic%private = .7� , Drilled Dia. of Well Casing 5 ina , p as ac <br /> ~' Domestic/public r Driven Gauge of Casing Class <br /> Irrigation .., Gravel, Pack.,.-, Depth of Grout Seal (25 #t. <br /> Cathodic Protection `* - Rotary _ '" <br /> Type of Grout Cement, 000 <br /> Disposal Other Other Information <br /> Geophysical _' �� e — Surface Seal Installed 'By:-- <br /> PUMP <br /> B PUMP INSTALLATION: <br /> Contractor Owner <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT:: <br /> / / State Work Done <br /> PUMP "REPAIR: I I State Work Done r <br /> DES TRUCTiON OF WELL Well Diameter Approximate Depth, I <br /> None 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 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 F <br /> information is true to- the-best -of.-my knowledge and belief. I WILL.CALL_FOR,.A-:GROUT INSPECTION <br /> PRIOR, TO ROUTING AND A FINAL INSPECTION. <br /> SIGNED <br /> {DRAW PLOT PLAN ON REVERSE -SIDE s s i <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> :�, <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> -PHASE II GROUT INSPECTION— = r.. ,- -- PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -17 <br /> E H 1426 Rev. -1. -74 <br />