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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> FOR AE <br /> OFFICE U : 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 Issued12-77 <br /> (Complete In Triplicate) <br /> Application is Aereb made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the w herein des This application is made in compliance with San Joaquin <br /> County Ordinance No. 1 62 and the Rules and Regulations of the San Joaquin Local Health Di.str�ct. <br /> JOB ADDRESS/LOCATION , . H OF LOUI E AVE.j CENSUS TRACT <br /> EAST SIDE <br /> Owner's Name RAYMUS REALTY Phone 823-M h8'� ' <br /> Address 544 E. YOSEMITE AVE. City <br /> Contractor's Name RENNIN GS BROS. DRILLING CO.$INC . .License # 290813 Phone 545-11'85 <br /> 3525 PELANDALE AVE. , MOD. , <br /> TYPE OF WORK (Check): NEW WELL /z DEEPEN /-7 RECONDITION /-7 DESTRUCTION /_7 <br /> PUMP INSTALLATION /_7PUMP REPAIR /7—Pump REPLACEMENT /7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK IMI SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD /4VL+ CESSPOOL/SEEPAGE PIS, OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS a�. <br /> Industrial Cable Tool Dia. of Well Excavation 1111 <br /> __-XDomestic/private Drilled Dia. of Well Casing 6" pi a stj P <br /> Domestic/public Driven Gauge of Casing 160 wall <br /> Irrigation Gravel Pack Depth of Grout Seal .50-t <br /> Cathodic Protection _ Rotary Type of Grout Beutonitte <br /> Disposal Other Other Information Slab-by owner <br /> r <br /> Geophysical Surface Seal Installed By: dxi.Ll P�� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT / / State Work Done (n <br /> PUMP -.REPAIR: / / 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 Distr ct <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 to the best of. my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION ' <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED BR0Q, DRILLING CO INC. BY TITLE--W zl.,-I"i <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> OR DEPARTWT USE ONLY <br /> PHASE I / � � <br /> APPLICATION ACCEPTED BY � /� DATE <br /> G _ <br /> ADEITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIONPHAS II F NAL INSPECT 0 <br /> INSPECTION BY DATE INSPECTION /BY DAT 0 <br /> E H 1426 Rev. 1-74 t' i "- , 1177 ' 2K <br />