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66 r <br /> SAN JOAQUIN .LOCAL HEAL <br /> r-�i:,,��QFtiCE USE: 1601 E. Hazelton Ave. , Stocktan� d'Ztf <br /> t . m, <br /> _ Telephone: (209)' 466-6781 r <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP p ZMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete <br /> eIn rettoconstruct <br /> Application is liereby de to the San JoquinLocalHalth District permit <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> Ir4County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Silva Ranch- W. of Hwy, 88,.-N. -Of Live Oak Rd. <br /> CENSUS TRACT _ <br /> Owner's-Name Corto passi Farms, Inc, c/�,,Automated Farm`,Systems Phone 931-4442 <br /> Address P. 0. Box 8600; Stockton, CA j9t204 <br /> City Stockton <br /> Contractor's Name Hennings Bros. <br /> - - License # 29081.3 -.Phone 1-522-1031 <br /> TYPE OF 'WORK (Check): NEW WELL/ 7( DEEPEN/ RECONDITION /� DESTRUCTIQN /� ' <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT /-7 <br /> Other J-7 <br /> DISTANCE TO NEAREST: . SEPTIC TANK 000 + SEWER LINES N/A PIT PRIVY N/A „* N <br /> SEWAGE DISPOSAL FIELD 2000'+ CESSPOOL/SEEPAGE PIT 20001+ OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL 2.Q00.'PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> industrial Cable Tool Dia. of Well Excavation 26' <br /> Domestic/private Drilled <br /> Dia. of Well Casing 14"' <br /> Irrigation <br /> w Driven Gauge of Casing 10 Gd (3/16") <br /> �— Irrigation 1 ��� Gravel Pack Depth of Grout Seal N/A <br /> i <br /> Cathodic Pry T <br /> otection Rotary i <br /> Disposal OtherYPe of Grout N/A <br /> Geophysical A Other Information,' <br /> µ Surface Seal :In B caner <br /> PUMP INSTALLATION: Contractor y N <br /> Type of Pump turb' H.P. <br /> _ -1.0lLk�p <br /> PUMP-REPLACEMENT / / State Work Done _N/A <br /> PUMP .REPAIR: a /�/ State Work Done N A <br /> DESTRUCTION OF WELL: Well Diameter ' <br /> Nom, .. -- 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 4 <br /> i forms 4mk is true o th best of knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR T GR D A AL INS P ION. <br /> SIGNED TITLE SE RU Cij <br /> TL <br /> DRAW PLff PLAN" ON RE FRSE SIDE car 804Wi p+ rE+ S <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> � <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PRASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 -74 ?.-7 G� <br /> Rev. 1 - " .: 3/.75 2M <br />