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SAN JOAQUIN LOCAL HEALTH DISTRICT � 1 <br /> F'ORrOFFICE USE:—'- 1601. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-o5W� <br /> f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued e-2-2-77 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health Disttict for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> C3 ( PS-0 S• 4.-• A-7)IJ � .2-5, 3 - 2s0--?Z <br /> JOB ADDRESS/LOCATION 1/4 Mi. S of Derham Ferry Rd; 112 Mi. E of Chrisman CENSUS TRACT <br /> Owner's Name Ruiz Bros. Phone 20 $ -l4 <br /> 53 <br /> Address 31313 S. Bird Road City ' Tracy, CA <br /> Contractor's Name Western Well Drilling Co. , Ltd. License # 251$2 Phone 295-4332 <br /> TYPE OF WORK (Check): NEW WELL -/-7 DEEPEN -/-7 RECONDITION /-7 DESTRUCTION 17 <br /> PUMP INSTALLATION /X PUMP REPAIR 17 PUMP REPLACEMENT %f <br /> Other /J <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 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 <br /> Domestic/private Drilled Dia. of Well Casing L� <br /> Domestic/public Driven Gauge of Casing <br /> . <br /> "Irrigatiot Gravel Pack Depth of .Grout Seal <br /> Cathodic Protection Rotary Type of Grout n <br /> Disposal r. , Other Other Information <br /> Geophysical - -- - led By: ' h. <br /> - ... - Surface Seal Instal <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump Vertigal H.P. 100 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: /-7 State Work Done " <br /> ES;TRUCTION OF WELL: Well Diameter Approximate Depth , <br /> Describe Material and Procedure <br /> I hereby afree 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 w <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health Districts, <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 knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR GROUTING AND A FINAL INSPE N. <br /> SIGNED _ TITLE President <br /> W PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BYDATE �- <br /> ADDITIONAL COMMENTS: - <br /> PHASE II GROUT INSPECTION PHA III F NAL INSPECTION } <br /> INSPECTION BY DATE INSPECTION BY DATt� /- <br /> E H 1426 Rev. I-74 1_74 9M <br /> k . <br />