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u .F ; �.. <br /> SAN JOAQUIN LOCAL HEALTH- DISTRICT . 5 . <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> i <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date issuedL_. ,4 d <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 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 1 241 Campbell Rd.• l mi No th of HWV 120, CENSUS TRACT <br /> West side <br /> Owner's Name Raymond Bettets Phone $1a-2594 __ <br /> Address 17241 Cam bell Rd _ City <br /> ` License #� Phone ' 1l1g1 <br /> Contractor's Name . Hennin s Bros Drilling- Co n � �--� <br /> 2500 W. Rumble Rd. MOd. i <br /> TYPE OF WORK (Check) : NEW WELL fXI DEEPEN/ / RECONDITION /� DESTRUCTION /� <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT /? <br /> Other./ <br /> DISTANCE TO NEAREST: SEPTIC TANK '�SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 2t1_[ tCESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE — PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool • Dia. of Well Excavation 11° <br /> X Domestic/private Drilled Dia. of Well Casing 611 plagtlr, <br /> Domestic/public DrivenGauge of Casing 160 wall -- <br /> Irrigation Gravel ,.Pack Depth of Grout Seal 50, <br /> Cathodic Protection _ Rotary Type of Grout Bentonite <br /> Disposal Other Other Information ' Slab-by owner <br /> Geophysical Surface Seal Installed B : driller <br /> 1 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: 1 / State Work Done <br /> JMP REPAIR: / / state Work Done <br /> S-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Ma rial a d Pr cedure <br /> k. <br /> I hereby agree to comply wit all laws and r gul ons of t e San oaq n Loca Health District <br /> and ,the State of California pertaining to or regulating well'construction. , Within FIFTEEN DAIS <br /> after completion of my work on a new well, I will furnish the San Joaquin focal Health Distridt 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. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED HENNINGS BROS.. DRILLI INC .. BY TITLE < G_C - x SEC <br /> DRAW:P T PLAN ON RE ERSE SIDE) <br /> FO DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> P II _ OUT INSPECTIO P I N4 INSPECTIO <br /> INSPECTION BY DATE ,C—� INSPECTION BY _ DATE} <br /> ZZ 3/76 ;2M <br />