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J � <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFs:OFFiCE USE; 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> �AP ICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 76-/l7D I� <br /> THS PERMIT EXPIRES l 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 Joaquin <br /> County Ordinance No. 1862 ana the Rules and Regulations of the Sae: Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION North side Dead-end of Sun Road &East Beecher Road CENSUS TRACT <br /> Owner's Name John Rossi. Phone ' <br />{ Address . x7.999 E. Sun Road, Stockton, Calif. 95205 Cit <br /> f � . �E - <br /> Contractor 1•s•-Name Pu-rvianee-DrillersTBox-64-1-Tinden•;,CGa'?-if:95 36"I,icet e- x•240=tO'7--.Ph ne'_`93 6 <br /> TYPE OF WORK (Check) : NEW WELL/ / DEEPEN -/7 RECONDITION 47 DESTRUCTION _/7 <br /> PUMP INSTALLATION /rtI PUMP REPAIR/-7—PUMP REPLACEMENT /xf <br /> Other -- <br /> P <br /> DISTANCE TO NEAREST: SEPTIC .TANK 5000. SEWER LINES FIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL 4 , CONSTRUCTION SPECIFICATIONS <br /> Industrial x Cable Tool Dia: of Well Excavation <br /> r..� Domestic/private Drilled }'# �Dis. of Well Casing <br /> Domestic/public a Driven 4 Gauge'df Casing <br /> z Irrigation t Gravel Pack i�epthiof Grout Seal <br /> Cathodic,Protection Rotary Type ;f, Grout <br /> Disposal �, ,� 1, 0th�' Other'-information ' C7,ean out sand & inataTT <br /> Geophysical. s Surface Seal Installed 'B 7-finer <br /> PUMP INSTALLATION: Contractor v � ` <br /> Type of Pump - H.P. ' <br /> Lj <br /> PUMP REPLACEMENT: • jg / State Work Done Insta7.l existing pump <br /> PUMP �REPAIR: / / State Work Done - . <br /> DESTRUCTION OF WELL: Well. Diameter -� - Approximate <br /> 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 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 therm 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 GROUTING INAL INSPECTION:. , <br /> SIGNED TITLE Partner <br /> {DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> ,' + <br /> APPLICATION ACCEPTED BY,,, ATE <br /> ADDITIONAL COMMENTS: - <br /> PHASE IIARMT INSPECTION ' P FWL INSPECTION <br /> INSPECTION BY dzz& DATE INSPECTION BY / DATE <br /> E H 1426 Rev. 1-74 <br />