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7;ec SAN JOAQUIN LOCAL HEALTH DISTRICT ". <br /> �7Ot. EFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (204) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 9 t� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued a_may <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 in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules apd Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION q_ ATj$TTN Rn..jMT G_ nF HDTV 1 p0_WF,,T gTnp CENSUS TRACT S- 5 <br /> Owner's Name JOHN ARATAKIS Phone 823-2502 <br /> Address ' LCL�,t� City <br /> Contractor's Name BENNINGS BROS, DgILL.ING,o. ,,T-NC. License # 11,6-A22 Phone 522-56_43 <br /> 2500 W. RUMBLE RD., MODEST0 <br /> TYPE OF WORK (Check) : NEW WELL /X7 DEEPEN /7 RECONDITION/—/ DESTRUCTION /7 <br /> AL <br /> PUMP INSTLATION /—/ PUMP REPAIR /-7 PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK $,j SEWER L NES 7 g_ PIT PRIVY <br /> \� _ SEWAGE DISPOSAL FIELD ?S- CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation low <br /> X Domestic/private Drilled Dia. of Well Casing 6 " d <br /> Domestic/public Driven Gauge of Casing 12 GA <br /> Irrigation Gravel Pack Depth of Grout Seal 502 <br /> Other X Rotary Type of Grout BENTONITE <br /> Other Other Information SLAB-. BY OWNER <br /> PUMPIINSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP UPAIR: / / State Work Done <br /> DFTRUCTION 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 to the--bst of my ,knowledge and belief. <br /> SIGNED TITLE <br /> (TAAW,4LOT PLAN ON REVERSE SIM) <br /> R DEPARTMENT USE ONLY <br /> PdASE I <br /> APPLICATION ACCEPTE Y DATE <br /> ADDITIONAL COMME-NTS: <br /> PF1.P, F,, II GROUT INSPECTION P I AL INSPECTION <br /> INSPECTION BY A-, :< DATE INSPECTIO DATE -5-- <br /> CALL <br /> — <br /> CALL EOR-A_GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 -- ---- -- �_ __ 5/731M <br />