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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE" FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. rJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued`'� � 9 <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 wor0 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 I Stoneridge CENSUS TRACT _ }- <br /> �I Phone g36'-0492 G.N <br /> E Owner's Name o e <br /> Address <br /> p. 0�. Box 326. <br /> City , :. .Trac . <br /> Contractor's 'Name Herenin s Brothers <br /> License # C57 Phone 545-1185 <br /> t DESTRUCTION <br /> TYPE-OF WORK (Check): INEW WELL / DEEPEN L-T RECONDITION I / <br /> i INSTALLATION/ /f PUMP REPAIR f / PUMP REELACEMENT 17N <br /> �:PUNP <br /> Other /.._/: 1 <br /> DISTANCE TO NEAREST: SEPTIC 7DISNPFIELD��l <br /> SES PIT PRIVY (1n <br /> SEWAGE CESSPOOL/SEEPAGE PIT OTHER 1 <br /> t PROPERTY LINE - PRIVATE DOMESTIC WELL <br /> CONSTRUCTION C 9PECIOMESFICATIC T WELL <br /> ; <br /> IONS <br /> INTENDED USEh TYPE OF WELL <br /> Industrial , Cable Tool Dia. 'of Well. Excavation <br /> X <br /> Domestic/private x Drilled Dia. of Well Casing 6" <br /> Domestic/public Driven Gauge of Casing pm, . tin <br /> Irrigation �, Gravel Pack Depth of Grout Seal 50 ' <br /> _Cathodic Protection Rotary Type of Grout <br /> Other Other Information <br /> Disposal <br /> Geophysical Surface Seal Installed B ritas <br /> ' <br /> PUMP -INSTALLATION: Contractor it s e t is H.P. 1 <br /> Type of Pump Jet- UM <br /> PUMP REPLACEMENT: - / / State Work Done <br /> PUMP .REPAIR- i j I State.Work Done <br /> t <br /> Approximate Depth <br /> DES•TRUCTION.,.OF WELL: Well Diameter <br /> ' <br /> Describe Material and Procedure r <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health H�.stDAT.9 <br /> and the State of California pertaining to or regulating well construction. Within BITiTE� SYS. <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 .Vell-.in use. The above <br /> j information is true to the best of my knowledge and belief. I WILL CALL POR A GROUT INSPECTIOR.. <br /> PRIOR T GROUTING AND A„FINAL INSPECTION. TITLE <br /> SIGNED77 <br /> pW P PLAN-ON RE E1tSE SI <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I li DATE v':z <br /> APPLICATION ACCEPTED. <br /> iBY <br /> ADDITIONAL'-COMMTS:1� PHASE III FINAL INSPECTION <br /> i PHASE II _GROUT IN ECTION INSPECTION BY TE <br /> INSPECTION BY ll�/�''-' DATE _ <br /> 3/76 <br /> a <br /> E H 1426 Rev. -I-74 <br />