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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> " F0r0FFICS USE; II: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ;I Telephone: (209) 466-6781 <br /> it APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77- 31� <br /> it <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (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 :Wade in compliance with San Joaquix <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 32-fos0 S. 0Rw- _)_s3_ 2s 0-0,6 <br /> JOB ADDRESS/LOCATION Eastside of Chrisman Rd; 1001 N. of- State Canal CENSUS TRACT <br /> Owner's Name Brichetto Estate Phone <br /> Address . 1601 W..�Lincoln Road - ' City Stockton <br /> Contractor's Name Western Well Drilling Co., Ltd. License # 25182 Phone 295-4332 <br /> A <br /> WW'OF WORK (Check): NEW WELL "/�" DEEPEN /7 RECONDITION 1-7 DESTRUCTION ,/7 <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT <br /> Other /% — — � � <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISP05AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL {� <br /> INTENDED USE R TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private' Drilled i Dia. of Well Casing _ <br /> Domestic/public !` Driven Gauge of Casing t <br /> Irrigation j� Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: � Contractor <br /> ; Type of Pump H.P. <br /> PUMP REPLACEMRNT: �i / / State Work Done . t <br /> � <br /> PUMP-!REPAIR:. :� <br /> ,. _;_�_ �, Work- ,.._.,. .. . .�-- � _ State DaneY�=--��:�:��-�- �- <br /> ES TRUCTTON OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <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,!"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 <br /> information is true tojthe•best of my knowledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR GROUTING AND A FINAL INSP ION. <br /> SIGNED TITLE Vice President 1/28 ??. <br /> .I� (D W PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �I <br /> APPLICATION ACCEPTED BY DATE � �"��� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P .. E IFINAL INSPEC ION <br /> INSPECTION BY 0- DATE INSPECTION. BYQII:ffDATE <br /> I' <br /> ` E H 1426 Rev. 1774 <br /> i - ." 1-74 2M <br />