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_�. SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephoner (209) 466-6781: <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 <br /> E , <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued2-ff� <br /> Com IereTn Triplicate)� - <br /> _ P P <br /> Application is hereby made to -.the San" oaquin 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 /> JOB ADDRESS/LOCATION NORMANDY VILLAGE, UNIT NO. 2 LOT #89 ' CENSUS TRACT <br /> k <br /> Owner's Name BARNETT-RANGE CORPORATION Phone 209 951 51_40_ <br /> i <br /> Address 1910 Dijon St. , Stkn. ; Ca. 95210 MAIL: P. 0. Box 8189 Stkn. 95208;ity <br /> Contractor's Name BARNETT-RANGE CORPORATION License # 312117 Phone ' (209 f� <br /> 951-5140 <br /> TYPE OF WORK (Check) :' NEW WELL/-T DEEPEN / / RECONDITION /-T DESTRUCTION <br /> PUMP INSTALLATION/ / PUMP REPAIR '/_/ PUMP REPLACEMENT /? <br /> Ot <br /> her <br /> DISTANCE TO NEAREST: ` SEPTIC TANK SEWER LINES --- PIT PRIVY <br /> t.aSEWAGE DISPOSAL FIELD -- CESSPOOL/SEEPAGE PIT -OTHER <br /> } PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC I OMESTIC WELL <br /> INTENDED USE 'TYPE-OF WELL .CONSTRUCTION- PECIFICATIONS'"' <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal: <br /> Cathodic Protection Rotary Type of Grout i <br /> Disposal Other Other Information <br /> . Geophysical,.-�-- �5urface-Sea1 Ins ta13e _B -: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /_7 State Work Done <br />�= PUMP:REPAI-R-•�. .�_ :. - /� :State-Wo rk,Zone— w_ <br /> . . . , - -,mss <br /> DESTRUCTION OF WELL: Well Diameter !� Approximate Depth 3651 >: <br /> Describe Material and Procedure_ fill to 50' with sand ;then concrete to ': <br /> - <br /> ' ca ..wi. th 'slab. <br /> I hereby agree to comply with all laws and regulat16ns of-the Sari Joaquin Local Health District I <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 GRO ING AND INAL IN ON. - . ."�""` -." ^" <br /> SIGN TITLE "Vic-President � <br /> Er <br /> Eli Barnett (DMW PLAN 'ON RE RSE SIDE G <br /> Arne - ange Corporation FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY /LTJ u DATE <br /> ADDITIONAL DOMMTS: <br /> PHASE II GROUT INIPECTION PHASE'.III FINAL-INSPECTION' . r <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> - - w <br /> A E H 1426 Rev. '1,74 �' . � �3/76 2M <br />