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r <br /> SAN JOAQU N LOCAL HEALTH DISTRICT <br /> FOE��OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Za- :2_y .J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE: ISSUED Date Issued 19w7L. <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 ,made Incompliance with San .Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations• of the San -Joaquin Local Health ,District. <br /> JOB ADDRESS/LOCATIONd -- orth- of French Cam Rd west CENSUS TRACT <br /> r side-. .. ., . . • <br /> Owner's Name Emil esen Phone 982-0810 <br /> Address 825 2. Dudley Rd. City <br /> Contractor's NameNNING BR . DRILLING CO. INC . License # 290813 Phone .. 522-1031 I <br /> 2 00 W. RUMBLE RD: MOD <br /> TYPE OF WORK (Check): NEW WELL /$'7 DEEPEN -/7 RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION '/% PU11P REPAIR -/ PUMP REPLACEMENT <br /> Other <br /> .'DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES f��.� PIT PRIVY d <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 Took. Dia. of Well Excavation _ 12tr � <br /> Domestic/private Drilled Dia. of Well -Casing, <br /> Domestic/public Driven Gauge of Casing 10 GA <br /> X Irrigation Gravel Pack.. Depth of Grout Seal'' 50, <br /> Cathodic Protection X Rotary Type of. Grout - _Bentonite <br /> Disposal - Other Other InformationSlab-by <br /> Geophysical Surface Seal Installed B dtiller <br /> PUMP INSTALLATION: Contractor � <br /> Type :of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Done . <br /> PUMP .REPAIR: /_7 :State Work Done . . . <br /> DESTRUCTION 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. €urnish 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 to the-best.of my. knowledge and belief. l WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING '.AND A FINAL INSPECTION. <br /> SIGNED =NjNGS_Bg0S, DRILLING CO. INC. BY TITLE SEC. <br /> DRAW PLOT PLAN ON REVERSE SIDE - <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I• 0, <br /> �'`'� , <br /> APPLICATION 'ACCEPTED: BY DATE <br /> ADDITIONiL COWENTS: .r. /► r. y _ <br /> PHASE Il GROUT INSPECTION •P SE III FIN INSPECTION oy-: <br /> INSPECTION .BY DATE 6 INSPECTION BY DATE <br /> E H 1426 Rev. 1--74 4/75 <br />