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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> _LOB.;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) 2-5s - 27-0- ? <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 wade in compliance with San Joaquiin, <br /> County Ordinance No. 1862 an'd the Rules and Regulations of the Sar: Joaquin Local Health District." <br /> JOB ADDRESS/LOCATION 1/4 Mi. South of Linne Rd; 50' East of Koste CENSUS TRACT <br /> Owner's Name Paulson Farms, Inc. Phone 209/835-1531 <br /> � <br /> Address 700 W. lAnne Road City Tracy <br /> Contractor's Name Western Well Drilling Go., Ltd. License 25182 Phone 295-4332 " <br /> TYPE OF WORK (Check): NEW WELL /? DEEPEN -/7 RECONDITION'/-7 DESTRUCTION %j ° N <br /> PUMP INSTALLATION /—j PUMP REPAIR / PUMP REPLACEMENT f7 <br /> Other, / / <br /> DISTANCE TO NEAREST: SEPTIC' TANK SEWER LINES PIT PRIVY <br /> SEWAGE: DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL i <br /> i INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial i Cable Tool Dia. of Well Excavation <br /> i Domestic/private i Drilled Dia. of Well Casing <br /> Domestic/public # Driven Gauge of Casing <br /> Irrigation - i Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout • <br /> i Disposal Other Other Information <br /> Geophysical Surface Seal Installed- By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP`:REPAIR.— �""�" ` - r- -;;:- Bow-l-Re l a.cement <br /> _ ,.._ ��'"State Work�'Doae - p <br /> ES�TRUCTION OF WELL: Well Diameter Approximate Depth <br /> P p <br /> Describe Material and Procedure <br /> 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 work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and no the before putting..the. well in use.. The above <br /> information is true to the beat of my owl dge and belief. i WILL CALL FORA GROUT INSPECTION <br /> PRIOR TOG UTI FINAL INSPECTIC. <br /> SIGNEDA. TITLE President 7/18/78 <br /> - (DM51E2T PLAN ON REVERSE SIDE <br />{ FOR DEPARTMENT USE ONLY <br /> PHASE I `J <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE Ii GROUT INSPECTION P SE II NAL INSPEC ON <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1--74 1-74 21 <br />