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SAN JOAQUIN LOCAL HEALTH DISTRICT Y <br /> FOR OFFICE"*tfSE; 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. = -- UJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date- Issued <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 /> JOB ADDRESS/LOCATION 21 35 River Rd. Near Van Allen CENSUS TRACT ~ YZ <br /> Owner's Name Nick- Bellino Phone 838-2866 <br /> Address 21423 River Rd. City Escalon <br /> Contractor's Name Bros. Drilling CO. Inc. License # 116322 Phone522-5643 <br /> 2 5QQ W.--- =fumble Rd. Modesto Calif. W`350 <br /> TYPE��F WORK (h c1t) c NEW'WELL /Xf DEEPEN /_/ rRECONDITION /?DESTRUCTION /_7 <br /> ��/PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> dtti-�r_/ / <br />` n F <br /> DISTANCE TO NEAREST• . SEPTIC TANK EWER LINES PIT PRIVY <br /> x SEWAGE DISPOSAL IELD _--i CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE , , TYPE�QF WELL CONSTRUCTION SPECIFICATIONS Vel <br /> Industrial 1 Cable Tool Dia. of Well Excavation 1111 % + <br /> �X Domestic/private Drilled Dia, of Well Casing _ <br /> I Domestic/public +-D riven ­ - - ­Gauge-of-Ca-sing 12 GA <br /> t Irrigation F Gravel Pack Depth of Grout Seal, , - - ---� .• <br /> 3- Other 11 X - Rotary . ti -Typeof Grout <br /> t _ Other Other' Information Slab--by '1 j <br /> PUMP INSTALLATIONS Contracor "^�, / a 51 <br /> Type of Pump <br /> PUMP REPLACEMENT- / / State Work Done _' f <br /> PUMPPAIR: <br /> R� / / State Work Done <br /> ESTRUCTION OF WELL: Well Diameter _ �, A Approximate �Depthi <br /> k 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 t or-regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new -wel177I will furnish the San Joaquin- Local Health District a <br /> WELL DRILLERS REPORT of the well and notify thein before putting the well_in ,use. The above- <br /> information is true to the best of my knowledge -and belief. - <br /> f. <br /> SIGNED TITLE <br /> {D OT LAN ON REVERSE SIDE --� <br /> 0 EP N X. <br /> USE ONL _1 _ .► r <br /> PHASE I <br /> APPLICATION ACC TE BY <br /> WP DATE �- - <br /> ADDITIONAL CO <br /> ROUTyINSPECT N -' P I NAL INSPECTION <br /> INSPECTION- BY DATE INSPE BY DATE <br /> CALL FOR7i GROUT_INSPECTION PR 0R TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />