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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif . <br /> FOR OFFICE USE• <br /> Telephone: (209) 466-6781 Permit NO. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued <br /> (Complete In Triplicate) permit to construct <br /> z Application is hereby <br /> ereintdescribedaquThisLocal <br /> applicatian ismade in <br /> District <br /> for <br /> compliance with San Jo4quin� <br /> and/or install the work <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. ; <br /> pCENSUS TRACT ' <br /> J�DRESS/LOCATION o �sj�� IN Rane 8E Section 7 <br /> l Phone 948-0494 � <br /> I Owner's Name Aldo TOE!inali <br /> City Stockton <br /> Address Si hwav an <br /> b2=5597 <br /> License # 76602 Phone <br /> Contractor's Name Clark Well & E ui ment Co• , <br /> J _ <br /> TYPE <br /> OF WORK Cheek) : NEW WELL F—/ DEEPEN/ / RECONDITION_ / DESTRUCTION F7 <br /> ' 3 PUMP INSTALLATION./ / PUMP REPAIR / / PUMP REPLACEMENT /� <br /> Otherill P_ITP�LIVVY <br /> F DISTANCE TO NEAREST: SEPTIC TANKl SEWER LINES <br /> S /SEEPAGE PI f` OTHER iP! <br /> SEWAGE DISPOSAL FIELD` kt8MpUBLIC DOMESTIC WELL <br /> f PROPERTY LIN ^��PRIVATE DOMESTIC WEL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Dia. of We11�'Excavation " <br /> Industrial X —Cable Tool „ <br /> . Domestic/private Drilled Dia. of,Well�Casing <br /> Driven Gauge ofl Casing 4 <br /> -'Domestic/public De th of/Grout Seal none <br /> X IrrigAtion Gravel Pack p, . �, none <br /> Rotary T,yp"e of Grout ' <br /> k Cancqdic Protection y .0ther Information ' <br /> "Disposal, Other , <br /> Geophysical$. Surface Seal Installed B <br /> PUMP INSTALL'XTION: Contractor H. <br /> Type of Pump <br /> [ PUMP REPLACEMENT: a, / / State Work Done <br /> PUMP �REPAIR: I/ <br /> State Work Done <br /> Approximate Depth <br /> kDESiRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> aquin ca <br /> lth <br /> : I hereb !agree to comply with all laws and regulations of deconstruction.LoWithinaFIFTEENtDAYS <br /> hereby <br /> !agree <br /> the State of California pertaining to or regulating we <br /> after completion of my work on a new well, I will furnish uthinSan <br /> the�welXnlnouse.HeThe habove <br /> rict <br /> WELL DRILLERS REPORT of the well and notify them before putting <br /> knowledge and belief. I WILT. CALL FOR A GROUT �INSPECTION <br /> information is true to the best of my <br /> `PRIOR TO GROUTING AND A FINAL INSPECTION. TITLE { <br /> SIGNED -- i, <br /> ELAN_.ON AEVERSE_SIDE)_--,..�--�-_ - <br /> - _ FORTDEPARTMENT USE-ONLY I> <br /> PHASE I DATE <br /> APPLICATION ACCEPTED <br /> ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION'" <br /> PHASE II GROUT INSPECTION ? T ; '.DATE �:,,?% <br /> INSPECTION BY 1. <br /> DATE INSPECTION BY,P�' <br /> 214 <br />