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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORfOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT WIRES 1 YEAR FROM DATE ISSUED Date Issued 6-3 =7,7 <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 and Regulations of the San Joaquin Local Health District. <br /> ..34643 "-r: !�"�v_a 12-4 /JPay: ,)- -- Ztv- 06 <br /> JOB ADDRESS/LOCATION SW corner of Bird Road and Highway 132 CENSUS TRACT <br /> Owner's Name Rose Bros., c/o Richard Rose Phone 209/835-1240 <br /> Address 30773 S. Tracy Blvd. <br /> City - Tracy, CA , <br /> Contractor's Name Western Well e11 ➢ril]ing Co. 7d. License # 25182 Phone 295-4332. <br /> 3 <br /> i <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN /? RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION )ff PUMP REPAIR /_7 PUMP REPLACEMENT fY <br /> Other <br /> s <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <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 , <br /> Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing; <br /> _= <br /> Domestic/public, � �.�. -_-Driven _ Gauge of.-Casing---- <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout' <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BV: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> Vprtira3 _. H.P. 125 , <br /> 1 3 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,.REPAIR: /_7 State Work Done L. <br /> ESIRUCTION 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. Withi ' <br /> n FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District Z <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 k9aVledge and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO.GROUTING D FINAL INSPECTIO . <br /> SIGNED TITLE President <br /> ( W LOT PLAN ON REVERSE SIDE .A <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: ' <br /> PHASE II GROUT INSPECTION PHME II SINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION <br />.4 E H 1426 ! <br /> Rev. 1-74 <br /> z_7A 7M , <br />