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' SAN JOAQUIN LOCAL HEALTH DISTRICT <br />{ <br /> FOR rOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <br /> Application,'is hereby made to the San{Joaquin Local lete In rHealth District foreei <br /> and/or install the work herein described. This application is made in compliancetwithnstruct San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local health District. <br /> JOB ADDRESS/LOCATION ZAe <br /> CENSUS TRACT <br /> Owner's Name Terra DeyejQpment Phone <br /> Address51 51E o lmandw od Dr. City -Manteca <br /> Contractor's Name H MBr D i11in Co. Inc. License #290813 Phone 22-.10 1i <br /> 2 0 W amble -d,,, Modesto <br /> TYPE OF WORK (Check) : NEW WELL <br /> DEEPEN ,/_7 RECONDITION /T DESTRUCTION /7 <br /> PUMP INSTALLATION / PUMP REPAIR /7 PUMP REPLACEMENT /-J <br /> Other /- <br /> DISTANCE TO NEAREST: S1 PTIC TANK <br /> :,q ,SEWER•LINES] I\ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION-�SPECIFICATIONS -, } <br /> Industrial Cable Tool Dia. of Well Excavation 2 11 ; <br /> Domestic/private Drilled Dia. ofWell Casing rr <br /> Domestic/public Driven Gauge of Casing , G� <br /> x L-Irrigation x Gravel Pack Depth of Grout Seal <br /> Cathodic Protection X Rotary Type of. Grout :C <br /> Disposal <br /> Geophysical/�6 Other Other Information a - b ovme r _ <br /> "� /� 'Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. - <br /> PUMP REPLACEMENT: / State Work Done <br /> -PUMP-!REPAIR: State Work -Done <br /> ES TRUCTION OF WELL: Well Diameter Approximate Depth j <br /> Describe Material and Procedure ---- <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Distract <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 <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 GALL FOR A 'GROUT IPECTION <br /> PRIOR TO UTING AND A ALGINS CTION. <br /> SIGNED <br /> TITLE <br /> 1 (D PLOT PLAN ON REVERSE SIDE ` <br /> PHASE I R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY(._ <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE Il GROUT INSPECTION P SE FINAL INSPECTION <br /> INSPECTION BY DATE <br /> INSPECTION BY —W--}I-n� <br /> F <br /> E R 1426 Rev. I-74 <br /> 1_7/. oikr <br />