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7Za <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> o—r.,;0r ICE USE-T-7 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 7-/ - <br /> (Complete In Triplicate) <br /> 1„ , Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> 4 and/or install the work herein described. , This application is made in compliance with San Joaquin <br /> County Ordi;nancO_ No. 1862 acid the Rules and Regulations of the San Joaquin Local Health Dis4rict. <br /> JOB ADDRESS/LOCATION ° gidp <br /> CENSUS TRACT 209 <br />[ ,. 'North of Hwy, 205 <br /> 'Owner's Name Charles Spa-tafore Phone 835 - 5804 <br /> Address <br /> 27880 South Lammers <br /> T <br /> City Tracy.' Calif, <br /> Contractor's Name Hennings Bros. Dri}_ling Co., Inc. License # 290813' Phone522-1031 <br /> 250Q W. Rumble Rd. M esto Calif. <br /> TYPE OI WpRK Check) NEW WELL ]X/ UE �”" <br /> PEN 7.' -CO-I-B�Tfo �J /_. TpucT— Nom' 9 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 (W" <br /> -- <br /> Other"-/-/ � <br /> U0 ISTANCE TO NEAREST SEPTIC TAINK -- p� EWER LIN-5 - —- <br /> SEWAGE DISP�ID CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED` USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial i Cable Tool Dia. of Well Excavation 11Ti , <br /> X Domestic'/private ! Drilled Dia. of Well Casing <br /> - Domestic%public i Driven Gauge of Casing inj <br /> Irrigation ! Gravel Pack Depth of Grout Sealr <br /> X RoRPn .nn;i:a <br /> �r <br /> Other 11 _ _ 1 tary Type of Grout <br /> t Other Other Information — <br /> T t, If _.. Slab by <br /> PUMP INSTALLATION: Contractor , : <br /> Type of Pump e.► H.P. - <br /> L <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP `iEPAIR: } / / State. Work Donee LSI <br /> ¢_ .. <br /> - :•.� ,..-•,.----. '--�.....,� �_..,�-:�- - -'.-cam.--:v_,_�...:_..,.� <br /> ,DFGTRUCTION 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 Californiapertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I mill furnish the 'San Joaquin Local Health District a <br /> WELL DRILIERSREPORT of the well and notify them before putting the well in use. The a ove <br /> information is true to the best of my knowledge and belief. <br /> SIGNED ' <br /> CLl"c . C TITLE <br /> ' DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Id % - . <br /> A.PPLICATION-ACCE-PTED.-.BY- - <br /> DATE <br /> ADDITIONAL =iiMNTS: y <br /> , PHASE II IO \ = P S II / AL INSPECTIO <br /> INSnH1426 <br /> N BY! AT INSPECT�I <br /> OR'.A,.GROUT INSPECTION_PRIOR TO GROUTING AND FINAL INSPECTION. <br />