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SAN JOAQUIN'I.AAL HEALTH DISTRICT <br /> FORiOFFICE 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 EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -!z-7q <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. 186 d the d Regulations of the San . oaquin Local Health District. <br /> Be Koster& Welt N. Sid <br /> JOB ADDRESS/LOCATION ✓. ewe tt Rd Be eCENSUS TRACT <br /> Owner's Name C' & AA Navarre, Ranch Carl Navarra <br /> Phone 83 835�.-285856 <br /> 2465 W. VRd'.Rd'. <br /> Address - - City ' Tracy, Cal. <br /> Contractor's Name Hennings-._. Bros. Drilling Co. , Inc- L #099913 Phone 522--56+3 i <br /> um e y . �� <br /> i <br /> TYPE_OF_WORK (Check).- ..,NEW-WELL DEEPEN. % RECONDITION- DESTRUCTION <br /> PUMP INSTALLATION / PUMP REPAIR /7 PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKIV,21Vf, SEWER LINES PIT PRIVY <br /> �( SEWAGE DISPOSAL FIELD _ CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL j <br /> INTENDED USE j TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial3 Cable Tool Dia. of Well Excavation <br /> X Domestic/private ! Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing �a?�rct. W , <br /> Irrigation Gravel Pack Depth of Grout Seal IN, <br /> Cathodic Protection; -_ X Rotary Type of Groutg i <br /> Disposal Other Other Information Slab by owner <br /> Geophysical _ Surface Seal Installed B nnin B o <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done r <br /> j <br /> PUMP :REPAIR: L7 State Work Done <br /> 1 r <br /> -:�. _-s.�. ._:..tom��.._y.. ��.:��I <br /> ESRUCTION-OF WELL: f WeZI'D�ameter 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-best of my-knowledge and belief. I WILL CALL FOR A •GROUT INSPECTION <br /> PRIOR TO ROUTING AND A FINAL INSPECTION. <br /> k SIGNED` TITLE <br /> X(DRAV PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY h DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION PHASEI FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -2 <br /> 1 _ <br /> i �' E H 1426 Rev. 1-74 1-74 2M <br />