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A <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601. E. Hazelton Ave:, Stockton, Calif. t <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 z G � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ,I,SSUED Date Issued 6-0-7.Y ' <br /> (Complete In Triplicate) 0.53—(2-0-0,0 1 <br /> Application is hereby made to',Ithe 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 and1the Rules and Regulations of the San Joaquin Local Health District. ¢ <br /> %!x Jac`?�• <br /> JOB ADDRESS/LOCATION Mile S. Kettlemen at end of Linn Road CENSUS TRACT 7 <br /> , z <br /> Owner's Name. . <br /> James Barnett Phone ' 36 .3922 <br /> Address 22220 N. !Lwy99 Aeam o Gaiif City <br /> Contractor's Name Parviance Drillers License # 24.0-107 Phone 931-446$ <br /> TYPE OF WORK (Check) : NEW WELL;/ `I_ DEEPEN—/ RECONDITION I_T DESTRUCTION 17_ 17 <br /> 7 A t <br /> PUMP INSTALLATION/a/ PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTICjTANK SEWER LINES PIT PRIVY may' <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial t Cable Tool Dia. of Well Excavation <br /> Ir Domestic/private ! Drilled Dia. of Well Casing <br /> Domestic/public s Driven Gauge of Casing <br /> Gravel-Pack-- _-Depth -of Grout Sea-1 . - <br /> Other I Rotary Type of'Grout <br /> t <br /> Other InformationOther <br /> z✓ <br /> f PUMP INSTALLATION: Contractor P Dr H.P.-/9 <br /> Type of Pump T H10Q <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> Approximate`Depth <br /> DESTRUCTION OF WELL: Well Diameter -- <br /> Describe Material and Procedure <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 <br /> after completion of my workton a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to a best of my knowledge and belief. <br /> f d TITLE Partner <br /> SIGNED (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> f ADDITIONAL COMMENTS: PHASE III/FINAL INSPECTION <br /> PHASE II GROUT INSPECTION DATE ',/0 /e` 73 <br /> INSPECTION BY DATE INSPECTION BY <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 4/72 1M <br /> E E H 1426 <br />