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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. _ <br /> 7V_I?V7 Ile, <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued e-1- <br /> (Complete <br /> r(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 /> , <br /> 'bounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 19299 S.Van Allen Road , Escalon <br /> CENSUS TRACT `S� <br /> William Lial <br /> Owner's Name Phone 59973688 <br /> 18299 River Road Ripon Ripon <br /> Address City <br /> -Contractor's Name - A.Hageman & Son License2898 Phone 599-3287 <br /> TYPE OF WORK (Check); NEW WELL DEEPE�N RECONDITION /-T DESTRUCTION r7 <br /> PUMP INSTALLATION /XI PUMP REPAIR /77 PUMP REPLACEMENT-' ' f7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC'TANK' SEWER LINES ,. PIT= PRIVY <br /> SEWAGE DISPOSAL FIELD 110' CESSFOOL/SEWAGE PIT OTHER <br /> PROPERTY' LINE 241RIVATE DOMESTIC WELL . PUBLIC DOMESTIC WELL �O <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation j <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing -- / 7 <br /> Irrigation Gravel -Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout 4=6LM <br /> Disposal __ Other Other Information R " 11 <br /> Geophysical Surface Seal Installed By: HAC-PLAQ94J <br /> PUMP INSTALLATION: Contractor Modesto Pump ;Service, Modesto. ` <br /> Type of 'Pump Immerseble H.P. t 2 <br /> PUMP REPLACEMENT: / / State Work Done. <br /> PUMP !REPAIR: /7 State Work Done <br /> ES:TRUCTION OF WELL: Well Diameter ApproximateJ�Depth-­,_/A001 <br /> DF <br /> escribe Material and Procedure 1 <br /> Y . <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District f <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 .1 <br /> information is true to the-best of my knowledge and belief. I WILL CALL FOR A -GROUT INSPECTION <br /> PRIOR TO GROUT NG AND A FINAL INSPECTION. <br /> SIGNEDTITLE Contractor <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DE TMENT USE ONLY <br /> PHASE I � <br /> APPLICATION ACCEPT . DATE U�- <br /> ADDITIONAL COMMENTS: <br /> GROUT INSPECTION PHASEII FINAL INSPECTION <br /> INSPECTION BY Jill DAT INSPECTION BY DATE W <br /> ! µE H 1426 <br /> Rev. 1-74 �"'r <br />