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Ek ev/ SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466 -6781 <br /> n� APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ?6-�f,?I <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued. .,? <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 Joaquin3 <br /> i County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> r JOB ADDRESS/LOCATION Z�AWR NdE RD=END OF ROAD j SOUTH SIDE OF CENSUS TRACT-2Y7-- �� 0`� <br /> HWY 120 6001 SOUTH & 13001 EAST { <br /> Owner's Name B & B_ BI�ARDEN Phone 522-1941 <br /> Address 3033 E. ORANGEBURG AVE. City MO DRIgTO <br /> 'Contractor's Name H_ ENNINGS I BROS.__DRILLING 'CO.. 6TN( . License # 29D81 3 Phone ' 5p_j()Tj <br /> A; <br /> 2500W. RUMBLE RD. MOD-. <br /> TYPE OF WORK (Check) : NEW WELL /Xf DEEPEN '/—/ RECONDITION / /_DESTRUCTION /7 <br /> i PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br />{ Other }/ / <br /> DISTANCE TO NEAREST: SEPTIC ,TANK. 17Me SEWER LINES ntn e.- PIT PRIVY <br /> SEWAGE DISPOSAL FIELD nbXo CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELLJ1_Q_tC- PUBLIC DOMESTIC WELL R�yy <br /> " INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation P 4": <br /> }" <br /> Domestic/private . I Drilled Dia. of Well Casing 16" <br /> �.,_-; . Do�_sticlpubl cam„ . _ _-.Driven Gauge of Casing' 3*,F"'3L'. <br /> X_ Irrigation X Gravel Pack? Depth of GGrout Seal <br /> Cathodic Protection X Rotary Type of Grout <br /> Disposal Other Other Information Slab- jbv owner __ <br /> Geophysical Surface Seal Installed By: <br /> E PUMP INSTALLATION: Contractor <br /> ' Type of Pump H.P. <br /> i Pim REPLACEMENT: . / / State Work Done �. <br /> PUMP .REPAIR: / / State Work Done Q <br /> DES-TRUCTION OF WELL: Well Diameter' Approximate Depth <br /> Describe Material and Procedure <br /> _:.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 j <br /> WELL DRILLERS REPORT of the well and notify them before putting the.-well in use. The ,above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GFLOUTING AND FJNAL INSP CTIO ± <br /> SIGNED ' LE <br /> DRAW T PL ON RE'VER SIDE) <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 7 Z � I <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT. INSPECTION PHA5 IIVFTNAL INSPECT N � <br /> INSPECTION BY DATE INSPECTION BY ADATE <br /> E H 1426 * ;„Rev. 1-74 �_ ,, �s. : <. ; , 376, 2M l i <br />