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/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Foo OFFICE USE: 1601 E. Hazelton . e. , Stockton, Calif. ` <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,QZ 76&) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued wyl,l I <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 /> JOB ADDRESS/LOCATION 2069601 South Manteca Road -CENSUS TRACT -.5. <br /> E <br /> • i <br /> Owner's Name Schmiedt' s Soil Service Phone 823-5315__ <br /> Address 20696 South Ma4eca Road city <br /> Contractox's»Name, .Henn ngS�STo.s..- D.rill- j,-j, Inc-._L� c.6r-1 e-_#-116322--Phone 522=6643 <br /> TYPE OF WORK (Check): NEW WELL /R/ DEEPEN / J RECONDITION /77., DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / . / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 'PIT PRIVY <br />-�- SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> : <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 13tr _ <br /> Domestic/private Drilled Dia. of Well Casing Rte' v6 <br /> Domestic/public Driven Gauge of Casing 12 '� 1 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other X. Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> < p <br /> `PUMP REPLACEMENT: / / State Work Done <br /> F <br /> t_i'-UMP--RERAIR•:=�� -/77/---;-State- Work, Donee <br /> .R•ESTRUCTION OF WELL: Well Diameter Approximate Depth <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 /> tl 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 notify them before putting the'well fn use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED r TITLE <br /> /--/(DRAW- PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ' <br /> APPLICATION ACCE ED BY DATE ` - <br /> ADDITIONAL COMMENTS: <br /> PHASE II `- OUT INSPECTION PHASE III FINAL INSPECTION. <br /> INSPECTION BY ti- DATE Z,, - INSPECTION BY DATE ` <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING -AND FINAL INSPECTION. - <br /> E H 1426 7/72 _lM <br />