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t. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR+rOFFTCE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> f I <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued • s?� <br /> t' (Complete In Triplicate) /3_ 2sib —2_�D <br /> Applicatioi 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 !_S a ai*;Rd 00t North of HLw0CENSUS TRACT - <br /> Owners Name Rudy Dell',Osso <br /> Phone 982--0833 <br /> Address 26 W. Stewart Rd. City Lathrop', Cal. <br /> Contractor's Name Hennings Brost Drilling Co. ; Inc. L cense # 2908�3 Phone 522-103.1 <br /> -2.500 Wo Rumble <br /> 1p �'4�tl31 1`�Ls I rr�f <br /> TYPE OF WORK ,(Check): NEW WELL /77 DEEPEN /? RECONDITION /- DESTRUCTION f7'-' <br /> PUMP, xNSTALLATION <br /> "PUMP- REPAIR / _PUMP-RE—PLAGEMN'`I % ]--- <br />_ <br /> DISTANCE TO NEAREST: SEPTIC TANK- a"""""""SEWER LINES PIT PRIVY <br /> ? ' SEWAGE DISP©SAL F.IELD:� ')r.> CESSPOOL/SEEPAGE PIT OTHER <br /> E PROPERTY ,LINE -- PRIVASTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial i } ' `Cable Tool Dia,, of Well Excavation 12" r ,� <br /> Domestic/private � ; Drilled' Dia:�'of`Well Casing , �✓i <br /># Domestic/public Driven,4 GaugeJ'of' Casing 12 Ga <br /> Irrigation Gravel,Pack Depth' of Grout Seal 0f <br /> Cathodic Protection - Rotary' " Type of Grout Bentonite <br /> Disposal = Other-"",,' .. Other information lab -b owner � <br /> Geophysical Surface Seal Installed By: Driller <br /> PUMP INSTALLATION: Contractor - k -- "� � ►- , �f <br /> -f Type of 'Pump H.P. <br /> PUMP REPLACEMENT: �v. Done ~Y <br /> / / State Work Done, <br /> SUMP_!REPA� _ Sxa•te W <br /> _ IR.�.�..,. ... � -/_7 - ork.'Done <br /> ES;TRUCTION. OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply withiall 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 onla new well, I will furnish the San .Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before puttingthe well in.use.. The above <br /> information' is true to the-beei-of- my knowledge and belief. I WILL CALL FOR A -GROUT INSPECTION <br /> ' PRIOR TO GROUTING AND A FINAL I INSPECT ION. <br /> SIGNED TITLEes <br /> 1 (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPART . T USE ONLY <br /> APPLICATION ACCEPTED- TE;�3-Y; �i ,�- ., ,�' `� .�'. f�•,_- �, <br /> ADDITIONAL CONI_MNTS•:1 <br /> J .PHA$F, II GROUT INSPECTION P S III INSPECTION <br /> INSPECTION BY c Ui DATE �.-6-'��' INSPECT BY DATE _ - ,5 <br /> E H 1426 Rev. 1-74 1-74 2M <br />