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" M <br /> 1 i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ` 1601 E. Hazelton Ave. , Stockton, Calif. <br /> E OF.:OI:F1Cb US1�,: � <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued z-2 J3 <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 /> Jos ADDRESS/LOCATION Next door to Crop Dusting airport .. '2"LcYCENSUS TRACT - <br /> 'Owner's Name Richard Rose <br /> Phone 4i5_365-»2017 <br /> Address 1+70 Beresford St. <br /> City .Redwoodgiyj Cal <br /> f , Inc* License # 116322 Phone522'--5643 <br /> LI-A� contractor s mama e nin Bros. Drilling Ca. <br /> e to Calif. <br /> trhei ) • *NwLL:- =, E -/ RECONDflN ./o <br /> 1sRrIc�rorr <br /> x = PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT / <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TP... K SEWER LINES PIT PRIVY ILU <br /> SEWAGE DISPOSAL FIELD 90' CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE ,!: TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> C Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing I 21t <br /> Domestic/public Driven Gauge of Casing 1P nut,/4�1 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other x -- Rotary Type of Grout 'nto <br /> Other Other Information 91,ab by Owner-- <br /> PUMP INSTALLATION. Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /` / State Work Done <br /> ! PUMP 'REPAIR: / State Work Done <br /> __ <br /> Approximate Depth <br /> DRCTRUCTION OF WELL: Well Diameter pp -- - <br /> ;, Describe Material and Procedure <br /> I hereby agrees to comjly with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well "constructi.on. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> I4ELL DRILLERS REPORT of the Drell and notify them before putting the well in use. ' The above <br /> information is true-to the best of my knowledge and belief. <br /> Seco <br /> SIGNED <br /> —(DW tvFOn!R�4EPP <br /> LAN ON REVER SIDE <br /> 't <br /> ARTMENTUSE NLY <br /> PHASE I `� TE _1 <br /> 'XPPLICATION ACCEPTED .BY ry &NAL <br /> •7 T 73 <br /> ` ADDITIONAL. COMME <br /> P ` $ ROUT INSPECT ON P INSPECINSPECTI DATE ` 7 INSPECTION BYDATE <br /> �- <br /> CALL-FOR A-GROUT INSPECTION'PRI4R TO GR TING AND FINAL INSPECTION. <br /> 5/731M <br />