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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF..-OFF10E USE; 11601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPL CATION(FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.J -✓r�r <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued,7-/ - <br /> t (Complete In Triplicate) <br /> i.,. Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> l 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 fA2DDRESS/LOCAT 4 <br /> PafitarGon Paso Road wP�qt ;eiP T CENSUS TRACT zo9- 080-2(a <br /> North of Hwy, 205 <br /> Owner's Name Charles Spataf ore Phone 835 - 5804 <br /> Address 27880 South hammers <br /> City Tracy_ Calif. <br /> Contractor's Name Hennings Bros. Drilling Co.� Inc. License # 290813 Phone522-1031 <br /> ?50 W. Rumbje Rd.- Mori to Calif. <br /> TYPE OF WOR Check): NEW LL X/ D PEN �` RE-00- BYTLON` �— 1f TRUCTIGN-f-7--- �- <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 Wy <br /> Other' /J <br /> ISTANCE TO NEARE5T: SEPTIC TANK1p <br /> ��'EWER LIN �~ <br /> 1 SEWAGE DISPO � D CESSPOOL/SEEPAGE PIT OTHER 1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial # Cable Tool Dia. of Well Excavation 11" <br /> X Domestic'/private ! Drilled Dia. of Well Casing <br /> Domestich" <br /> /Public i Driven Gauge of Casing i <br /> Irrigation 1 Gravel Pack Depth of Grout Seal t _ <br /> Other <br /> I X_ Rotary Type of Grout Rantoill _ ��, <br /> # 3 Other Other Information _ Slab by��er <br /> r <br /> PUMP INSTALLATION: Contractor <br /> ! Type of Pump e,/ }.� <br /> H.P, . <br /> # <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP UPAIR: / / State Work Done.-. > <br /> ,DFsTRUCTION OF WELL: Well Diameter -� <br /> Approximate Depth <br /> Describe Material and Procedure <br /> i <br /> I 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 f <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERSiREPORT of the well and notify them before putting the well in use. Thea ave � <br /> information is true to the best of my knowledge and belief. # <br /> SIGNED <br /> o CiAlc sc �t"_ TITLE -ll✓�7�� <br /> DRAW PLOT PLAN ON REVERSE SID L <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ( r , <br /> APPLICAT-r(514'-ACCER'DEn.-.BY '' DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II IOP S II' AL INSPECTIO <br /> INSPECTI-0N BY AT INSPEC .BY DATE <br /> CALL F'OR'.A,GROUT INSPECTION_PRIOR TO GROUTING AND FINAL INSPECTION. <br /> �..(' <br />