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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> . FOBrOFFICE 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 1 YEAR FROM DATE ISSUED Date Issued 6-01 1 .77 <br /> (Complete In Triplicate) <br /> Application is hereby .m�ade 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 /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 1/4 Mi. E of Chriaman; 1/2 Ili. S of Dttrham Ferry . CENSUS TRACT <br /> Owner's Name Marchese Farms Phone 2 8 1 <br /> 82 <br /> Address 631 Gaffe Road ?. <br /> City Verna],is, CA <br /> Contractor's Name Wel8tern Well Drilling Co., Ltd. License # 25182 Phone 295-4332 <br /> i <br /> TYPE OF WORK (Check).6 -NEW WELL /-7 DEEPEN /_� RECONDITION /? DESTRUCTION _ � <br /> PUMP INSTLATION / PUMP REPAIR /-7 PUMP REPLACEMENT <br /> AL17 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES FIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT— OTHER � <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE .I1 TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial II Cable Too! Dia. of Well Excavation <br /> Domestic/private ,`. Drilled Dia. of Well Casing , <br /> _Domestic/public„F.L . . Driven_ _ .0au e,of,.,Casing - - — _ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other ` Other Information <br /> Geophysical Surface Seal I _ <br /> . Installed By:,... <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump Vertical H.P. 125 <br /> I <br /> PUMP REPLACEMENT: / State Work Done <br /> PUMP '.REPAIR: IC <br /> / State Work Daae -; <br /> i <br /> IN <br /> PES. RUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> Il <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 /> after completion of my �iork on a new well, I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPORT ofl[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 CALL FOR A GROUT INSPECTIO <br /> PRIOR TO ROUTING .I�FINAL INSPECTIO . <br /> SIGNED <br /> 141- Z_ TITLE President. <br /> .�j (D PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY; DATE ! 7 <br /> ADDITIONAL CONMENTS: j <br /> PHASE II GROUT INSPECTION PEAE I I INSPECTION <br /> INSPECTION BY V DATE INSPECTION BY ATE <br /> i xE H 1426 <br /> - _ Rev. 1-741 1-74 2M <br />