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F e"- <br /> =--�i �/ V SAPS JOAQUIN LOCAL HEALTH DISTRICT � -f- 7s- <br /> 37OF ,,'OFFICE, USE: 1.601. 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 � p=� <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 /> u County Ordinance .No. 1862 and the. Rules and Regulations of the San Joaquin Local Health District; <br /> 20 <br /> JOB ADDRESS/LOCATION S. Na lee Rd.-between Larch & Bethany CENSUS TRACT <br /> Tracy <br /> owner's Name J. Norman Emrich Phone 415-447-4479 <br />'s Address 5250 Norma Way City Livermore <br /> Contractor'-s Name -Henn.i-ng.s,4B-r_os_.-,.Drilling_Co.- —Inc._ L-;.Li.cense-it.�l-i_b3.22-Phone 522�61_Q <br /> 270-0W, Rum e R . Mo es o, CalEr. <br /> TYPE OF WORK (Check): • NEW WELL/x/ DEEPEN/ I RECONDITION / f DESTRUCTION /_7 <br /> f PUMP INSTALLATION / / PUMP REPAIR '/ / PUMP REPLACEMENT /7 <br /> i. <br /> Other -/ / <br /> DISTANCE TO NEAREST: SEPTIC TAidK 5-0 SEWER LINES PIT PRIVY I' <br /> SEWAGE DISPOSA IELD�� CESS L/SEEPAGE PIT - OTHER <br /> i <br /> E <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> i Industrial Cable Tool Dia, of Well Excavation 1011 , <br /> __X Domestic/private Drilled Dia. of Well Casing 64:tt. A <br /> � <br /> Domestic/public Driven Gauge of Casing T _ '12 _GA -- -- .� <br /> Irrigation Gravel Pack Depth of Grout Seal 50� <br /> Other x Rotary Type of Grout Bentonjte <br /> Other Cather Information� - Slab- by owner .- <br /> PUMP INSTALLATION: Contractor � ' <br /> Type of dump H.?. . . <br /> y <br /> PUMP REPLACEMENT: / / State Work Done f <br /> t <br /> PUMP TZEPAIR: / / State Work Done J- /7 <br /> r 7 <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 />:j 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 notify them before putting the well in use. The above <br />? informati n is true to th best of my knowledge and- belief. <br /># SIGNED TITLE <br /> (D LAN ON REVERSE SIDE) <br /> t /0 -l b-7�" QR DEPARTMENT USE ONLY '-7 <br /> PHASE I 5P,^Ar AS 75-/-22W <br /> APPLICATION ACCEPTED .BY '� DATE <br /> ADDITIONAL COINaIENTS: <br /> PHASE JI GROUT INSPECTION � : PHASE III/FINAL INSPECTIQN <br /> INSPECTION BY DATE INSPECTION BY DATE t /V . <br /> • •CALL„I'OA,-)GROUT INSPECTION PRIOR TO GROUTING AND-FINAL INSPECTION. <br /> E 1 1426 5/731M i <br />