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4 r <br /> x F, <br /> lA° SAN JOAQUIN LOCAL HEALTH DISTRICT <br />! FOR OFFZGE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ` Telephone: (209) 466-6781 <br /> w APPLICATION FOR WELL, CONSTRUCTION OR PUMP PERMIT Permit No. <br /> I 1 7?/- <br /> i <br /> THIS PERMIT,EXPIRES 1 YEAR FROM DATE ISSUED , Date Issued <br /> I (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 with San Joaquin <br /> County Ordinance No. 1862 and-the -Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION � RIVER ROAD OFF NORTH RIPON CENSUS TRACT ' <br /> Owner's Name ERNEST 'AZAVEDID Ol GREENWICH LANEf <br /> Phone 524-1098 <br /> Address- MODESTO CALIF. <br /> - City <br /> Contractor's Name* k `i ''' ;F <br /> Tennin s [Brothers'-.=�}rillin Co3 Ine.License ;116322 Phone 5225643 <br /> TYPE .OF WORK (Check) : NEW:WELLwZX/ . DEEP_EN / / RECONDITION /_7 DESTRUCTION /_7PUMP INSTALLATION / /. _ <br /> PUMP REPAIR ' / PUMP REPLACEMENT 1_7 <br /> Other - ! <br /> i <br /> DISTANCE TO NEAREST: SEPTIC•,TANK SEWER LINES PIT PRIVY , <br /> SEWAGE'fDISPOSAL FIELD CESSPOOL/SEEPAGE�PI' - t OTHER - <br /> 4 - <br /> INTENDED USE TYPE OF WELL _ CONSTRUCTION SPECIFICATIONS <br /> _ Industrial = I Cable Tool `Dia.. of ,Weli;Excavation_._ • - .�O <br /> a <br /> -A Domestic/private 1 Drilled �� Ti ;, f Well Casing <br /> Domestic/public Driven F. Gauge of Casing f1 <br /> Irrigation ;:i _Gravel .Pack`" Depth of Grout Seal Sp � i. <br /> Other <br /> �X Rotary Type of Grout r ; <br /> Other Other Informatioii.' <br /> t <br /> PUMP INSTALLATION: Contractor0 ! <br /> E <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done ' <br /> - <br />-PUMP-REPAIR.:- =x"' 4 / /-Stater•Work-Done­-�:_ ......r <br /> .3ESTRUCTION OF WELL: Well Diameter ! <br /> ,. 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-REP.ORTYof}the-well...and_no.tify�them„be'f.ore-putting_the-well,-in_use.,_._Ths_above <br /> information is true to the best of my,knowledge and belief. <br /> t SIGNED ..tz > i` .TITLE <br /> oor (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> ,PHASE -I <br /> APPLICATION ACCEPTED BY DATE^ �lp <br /> ADDITIONAL COMMENTS: . <br /> PHASE II- GROUT INSPECTION PE I INAL INSPEC N <br /> INSPECTION BY DATE INSPECTION B DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL WqVW� <br /> CTION. j <br /> E H 1426 4/72 IM <br />