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4�. <br /> Si <br /> 3OAQUIN LOCAL HEALTH DISTRICT <br /> Stockton, Calif. <br /> 1 O1. 01 k 1C1: 1351:: 1601 E. Hazelton A e, <br /> 1 Telephone: 9) 466-6781 Permit No.,75 11 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT <br /> IDate Issued <br /> 1.`��_/7-3THA PERMIT EXPIRES 1 YEAR FROM DATE. ISSUED - <br /> (Complete In Triplicate) ext►iC to construct <br /> an <br /> gibed. ' This application is made in compli�aIljoalthSDistrict* <br /> n <br /> Application is hereby made t the pan Joaquin Local Health District or a permit <br /> and/or install the work herein des <br /> County ordinance -No. 1862 and <br /> the Rules and Regulations o£ the San Joaquin <br /> INo. 1 CENSUS TRACT ' <br /> JOB ADDRESS/LOCATION MIDDLE RD Phone S R 6 ----- <br /> Owner's Name SILAS WILLS City <br /> Address 1 000 MIDDLE RD. —- .�.. -�-- - <br /> r - ` License # Phone <br /> Contractor's .Name . .BENNING,9 BROS. DRILLING CO. INC <br /> 2 00 W-.. <br /> RUMBLE RD. MODE STO <br /> RECONDITION_ J DESTRUCTION I�T <br /> TYPE OF WORK (Check}: NEW <br /> WELL '/ DEEPEN I �� REPAIR I I P� REPLACEMENT J�T <br /> PUMP] INSTALLATION /! <br /> 0 the, J <br /> SEvWER LINES PIT PRIVY OTHER <br /> DISTANCE TO NEAREST: SEPTIC TA:SP CESSPOOL LO (SEEPAGE PIT p <br /> SEWAGE DISPOSAL FIELD d <br /> CONSTRUCTION SPECIFICATIONS <br /> { INTENDED USE i TYPE OF WELL n <br /> 1 n <br /> Cable Tool Dia. of Well L�xcavat�o !t ! <br /> Industrial Drilled Dia. of Well Casing - <br /> Domestic/private Driven Gauge of Casing <br /> Domestic/public Depth of Grout Seal <br /> De <br /> Irrigation Gravel Pack Type <br /> of Grout <br /> Other other y _. Other Information <br /> PUMP INSTALLATION: Contractor H.P. ' <br /> Type of Pump <br /> ..- UW REPLACEMENT:- _ /1/,- Sta a Work}one <br /> I'iTi� 'tEPAIR: State Work Done <br /> Approximate Depth <br /> DFTRUCTION OF WELL: Well Diameter <br /> p -ad Procedure <br /> Describe Material a <br /> herebyrict <br /> a ree to comply with all laws and reg ulations of the San ,Icahn LoWithin <br /> cal aFIFTEEN tDAYS <br /> I S pertaining to or regulating well''construction, <br /> and the State of California p I will furnish the San Joaquin Local Health District <br /> after completion of my work on a new �,rell, <br /> ore <br /> t <br /> } WELL DRILLERS REPORT o£ the well and notihmandfbelieft�ng the well in use. e above <br /> information is true to the best of myknowledge <br /> i TITLE <br /> ?ti SIGNED (DRAW PLOT PLAN ON REVERSE SIDE} <br /> POR DEPARTMENT USE ONLY <br /> t DATE <br /> PHASE I <br /> AP�� P A ION ACCEPTED .BY <br /> ADDITIONAL COMMENTS: PUA E III/FINAL INSPECTION <br /> PHASE 11 GROUT INSPECTION INSPECTION B DATE <br /> INSPECTION BY DATE <br /> . CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INS ECTION. 5/731M <br />