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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton- Ave',',',Stockton, Calif. <br /> Telephone:;:,,(2-01 )'4 466-16781 <br /> APPLICATION FOR WELL CQNSTRUCTIDN;'.Ok PUMP PERMIT Permit No. 7-5— IS4G(P <br /> THIS PERMIT,-,EXPIRES; l 1YEARdFROM.:DATE.,;IS SUED:.. ' ,'4Date�-18su6d '�V'� .-7.S <br /> Applicat*oiibigDhereby-:tmade-c-,to 1heo0anqJbaquiniLoL-a1, Health District'If br'-,a;,,pe-kmit--tb` co'nstru-i'C <br /> and/or install the work hereln' described. Thigf�applicationis;-.made.�in-,compliance:,with' San T.,Joaquin <br /> County i3prdinaiiceoNou1862w.aA4� <br /> th&r;Rud:e sL,andsRe gulat lions 6 f dthe,San':`Joaquin Local f iHe:al th"Dig tr:i c t., <br /> sfi' <br /> JOB ADDRESS/LOCATION 19901 E. Lone Tree Road -CENSUS`-TRACT <br /> om <br /> Owner.'s_��Nam&C�.[ `J). aDbt­iaigw6�wf'j bn t--,:) .838`,-2176-,-s�)o,1 <br /> Address 19901 E. Lone Tree Road City, Escalon. Calif...-., <br /> Contractor's Name I, J. Larsen: Pumps;, Inc, Lie en s Mntiuctoes"'TH6ne 529-2026 <br /> TYPE OF WORK- -(Check-)-::z-.-NEW-WELL�,/�/�.;,PEEPEN-��-/�--=.RECONDITION,7�AE�STRVqTI.ON,I-7 <br /> 7 <br /> PUMP''INSTALLATION' <br /> PUMP REPAIR '/x.:/ PUMP REPLACEMENT <br /> Other /. 7 <br /> DISTANCE TO NEAREST. "'SEPTIC"TANK" SEWER LINES ' PIT PRIVY <br /> 'SEWAGE.-DISPO$AL ..FIELD.,.- CESSPOOL/S EEPAGE_P_IT_ -. OTHER <br /> _4N <br /> 'INTENDED'--USE..`.......... .OF WELL", CONSTRUCTION-: SPECIFICATIONS <br /> Industrial. Cable Tool Dia. :of Well. Excavation <br /> Domestic/priVateDrilled Dia. of Well Casing <br /> Dbmest:Lc/publlc Dtiveri'. Gauge' of; Casing <br /> on... ... . <br /> Irrigati Gravel :Pack Dp <br /> e th:..of. Grout Seal <br /> .... .... <br /> Other Rotary - Type of Grout <br /> Other' other:"Inf ormation <br /> PUMP INSTALLATION:'�­ ' or <br /> Type:..of Pump-,..Contract - H.P. <br /> PUMP REPLACEMENT:' Staid Work Done <br /> .4 <br /> PUMP REPAIR: )!Z_7 State Work Done Pulled submersible pump, replaced mo-tor <br /> 7 <br /> .PESTRUCTION OF WELL:.. .." Well Diameter Approximate Depth <br /> Describe Matierial :and Procedure <br /> I hireby agree to comply-..with-all laws and regulations of the San Joaquin Local Health District <br /> and1the Stat& of' California Pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after­comn le tion; of: m' y' ". work­bii ci new wells I will furnish the San' Joaquin Local Health District a <br /> WELL _DkILLER& REPORT'. of the well-and notify them before putting the .well in use. The -above. <br /> inf8rmation is true:: to: the be: st�of :my ]kn6wledge, and belief <br /> iE <br /> ME <br /> SIGNED_ e] <br /> SIG J. LA TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPT D <br /> E' BY # DATEC/-Ze <br /> ADDITIONAL COMNENTS': <br /> PHASE 11...GROVT ;INSPECTION- PHASE Ijlj�X.;NAL INSPECTION <br /> DATE INSPECTION BY dao?5W <br /> INSPECTION BY. _4016- DATE 7/ <br /> BALL FOR A GROUT" IN8PECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 1.426 4/72 1M <br />