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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave., Stockton, <br /> Telephone: (209) 466-6781 -rte <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP <br /> PERMIT Permit 110' =1,�,�c. <br /> rw. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date issued - <br /> (Complete In Triplicate) reit to Construct <br /> :,ereby made to the San Joaquin Local Health District for a permit <br /> with San Joaquin <br /> the work herein described. This application is made in coup <br /> Local Health District- <br /> --e No. 1862 and the Rules and Regv'ations of the San Joaquin <br /> ,.,� rr >a _Y� RAST OF WAGEM RD.- CENSUS TRACT <br /> �.ATION •. , ,.�a nu -ti. SOUTH SIDE <br /> ALLEN RAN" CMCR MIDDLETON Phone <br /> 18700 E. RIVER RD. City RIPOF <br /> Name IiENNI <br /> NGS BROS. DRILLING CO. INC. License # 290R13Phoua -_2' � <br /> 25 W. RUWLE RD. MOD. e' <br /> (Check): NEW WELLA7 DEEkEN_/_T RECONDITION /-7DESTRUCTION LI <br /> PUMP INSTALLATION / / PUMP REPAIR / ] PUl� RHPLACElSEI1T r < <br /> Other ------------ <br /> NEAREST: SEPTIC TANK j2aye SEWER LINES A"g PIT PRIVT s <br /> SEWAGE DISPOSAL FIELD _LjaW.DOMESTIC <br /> PIT S I <br /> PROPERTY LIMB - PRIVATE DOMES CONSTRUCTION SPECIFICATIONS \ <br /> i`'['df:NDF.D USE Excavation <br /> TYPE OF WELL <br /> inustrial Cable Tool Dia. of Well 1bM�4M <br />;;omestic/private _ Drilled Dia. of Well Casing <br /> Gauge of Casing <br /> Domestic/public <br /> Driven ��•i <br /> Irrigation �_ Gravel Pack Depth of Grout Seal <br /> - <br />�,athodic Protection _ Rotary Otheof Grout <br /> Other Information^"n nv rrurfnA —� <br /> Disposal Other _ tallad By; • <br /> Geophysical Surface Seal Installs <br />[NSTALLATION: Contractor S H.P. <br />-' Tyve of Pump _ <br /> REPLACEMENT: / / State Work Done <br /> REPAIR: / / State Work Done <br /> Approximate Depth <br /> UCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> lth <br />.l,y tate to Californiacomply h all laws pertaining tnodoreregulating wellthe <br /> construction.�WithinaFIFTEENtDAYS <br /> t,. State of al P Joaquin Local Realth District a <br /> ,•omp7eCion of my work on anew well, I will furnish the San Joaq <br /> 1 !;IL1.t:RS REPORT of the well and notify them before putting the well in use. The above <br /> , 0 Ion is true to the best of my knowledge and belief. I WILL CA-LLL FOR A GROUT INSPECTION <br /> ROUTING AND A FINAL INSPECTION. BY TITLE SEC• <br /> „ . -INC. <br /> SE SIDE <br /> PLAN ON <br /> - t DEPART2ENT USE ONLY <br /> DATE Z <br /> A�.:(:EPTF.D Bell <br /> Y <br /> *lMEN TS: pHA I I FI INSPECTI <br /> I1 GROUINSP£CTION INSPECTION BY DATE <br /> PATE <br /> ./� - - -- 3/76 2M <br />