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t <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton"Ave% , Stockton, Calif. <br /> Telephone: (209) 456--6781 { <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 71-11301 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) ,2p q— ems"o-24 <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 /> Count _Ordinance No. 1862 and the 'Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION WEL , 2 Union Rd. one Mile S. of French CENSUS TRACT <br /> Owner's Name Joe Marchesotti ftmp 6 <br /> Phone .1+ <br /> ���� <br /> Address 1201 E . Alpine Ave. City Stockton, Cal. <br /> Contractor`s Name Heanings Bros. Drilling Co. Inc . License # Prone <br /> 116522 522-.5643 <br /> a500 W_ Pi1Tn'h1g- Pd . MndQst-o, �' <br /> Calif. <br /> TYPE OF WORK (Check) : NEW WELL j/ DEEPEN / / RECONDITION /'7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other /_7 <br /> N <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER d <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation t1k 24" _ P+ <br /> Domestic/private Drilled Dia. of Well Casing s ?It <br /> Domestic/public Driven Gauge of Casing 4 <br /> _ X _ Irrigation X Gravel Pack Depth of Grout Seal <br /> Other X Rotary Type of Grout <br /> Other Other Information Slab-By Owner T� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done o <br /> PUMP REPAIR: / / State Work Done ' <br /> ESTRUCTION 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 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 /> information is true to the best of my knowledge and belief. <br /> SIGNED I4 <br /> TITLE <br /> O (DRAW PLOT PLAN ON REVERSE SIDE <br /> (:T rFOREPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY / DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />