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z • <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> "OL OFFICE USI::. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7.3— � <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued X-,2�-713 <br /> (Complete In Triplicate) tY_O--I <br /> Application is hereby made to the Sart Joaquin Local Health District for a permit to construct <br /> and/or instlall the work herein described. ' This application is made in compliance with Sart Joaquin <br /> County Ordinance No. 1.862 a44 the Rules jaAd Regulations of the San Joaquin Local Heil.th District. <br /> 37ss_S• A e trl <br /> JOB ADDRESS/LOCATION OLD HWY 50 & CHRISMAN RD. N eI� C� CENSUS TRACT <br /> Owner's Name RANDY SASSER <br /> 14NRO S) Phone $3 5-2002- <br /> Address 220 --WEST-11th ST. City ' 'TRACY <br /> Contractor's Name HSNNINGS BROS. DRILLING CO. INC. License # 116322 Phone 522- 6� <br /> 77 <br /> _2 00_W_._RUMBLE RD_._ _.MODESTO <br /> TYPE OF WORK (Check) : NEW WELL ' DEEPEN/ / RECONDITION DESTRUCTION DESTRUCTION /7 <br /> PUMP INSTALLATION / / P[;'MP REPAIR '/ / PUMP REPLACEMENT /-7 <br /> Other 1_7 <br /> DISTANCE TO NEAREST: SEPTIC TANKfX, SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD Lj a CESSPOOL/SEEPAGE PIT OTHER �7_-3-� <br /> G <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> i Industrial Cable Tool Dia. of Well Excavation 12" <br /> ADomestic/private Drilled Dia. of Well Casing rr <br /> " Domestic/public Driven Gauge of Casing 12 GA <br /> Irrigation Gravel Pack Depth of Grout Seal 50' <br /> Other X Rotary Type of Grout BENTONITE <br /> Other Other Information SLAB-BY OWNER <br /> .t lH1h{r�r711y� '�`., �"(1, l lCA.(.!, Vk&.:t�. <br /> PUMP INSTALLATION: Contractor � �(� S~ <br /> --- Type of Pump _ S"M r•. a& H.P. <br /> _ Z <br /> PUMP REPLACEMENT: / / State Work Done 1; <br /> PUMP 'PAIR: / / State Work Done - " <br /> ,DFsTRUCTION OF WELL: Well Diameter - Approximate Depth <br /> Describe Material and iocedure . <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 /> sifter completion of my work on a new well, I will furnish the San Joaquin Local Health District l-i <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. <br /> SIGNED c ` TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> i FOR DEPART T USE ONLY <br /> i, <br /> PHASE I <br /> .APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASFOIII FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE <br /> i - CALL-FOR -A-GROUT INSPECTION-PRIOR TO GROUTING AND FINAL I S CTION. <br /> + 7 a I A9h .5/731M <br />