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,.. } SAN. JOAQUIN LOCAL HEALTH DISTRICT <br /> F0 ;OFFICE USE: 1601 E. HazeltonA . ,_ 4,tockton, Calif. <br /> Telephone (209) 466-6781 <br /> f APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7� <br /> F <br /> F <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> 4 Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> l <br /> and/or install the work herein described. This application is made in compliance with Sax Joaquir <br /> ! County Ordinance No. 1862. and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONr��REZNTER ,RD_ &. POCK LANE-1 MILE WEST _OF-_ CENSUS TRACT <br /> 11WY 99., SOUTH SIDE OF CARPENTER RD. <br /> Owner's Name HARRY SHREVE Phone <br /> Address <br /> 169 2',-HINTON ST. - � � City CA5-TRO VALLEY <br /> Contractor's Name HENNINGS BROS . DRILLING CO- ;INC . License # 290813Phone 5-118 J <br /> —.3525, PELANDALE AVE . 3 MODESTO CA . 0 e <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN / / RECONDITION / / DESTRUCTION /_ _ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT f / <br /> Other / / — <br /> R <br /> DISTANCE TO NEAREST: SEPTIC TANK 11Ot- SEWER LINES PIT PRIVY <br /> {- N <br /> t SEWAGE DISPOSAL FIELD Int CESSPOOL/SEEPAGE PIT OTHERWZLL-2 Ot <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 [ ');r <br /> X Domestic/private Drilled Dia. of Well Casing 6" PLA_S_T_IC <br /> Domestic/public Driven Gauge of Casing T 160 WALL. <br /> Irrigation X Gravel Pack Depth of Grout Seal _ 201 <br /> Cathodic Protection X Rotary Type of Grout BENTONITE <br /> Disposal Other Other Information SLAB-BY OWNER <br /> Geophysical Surface Seal Installed By: DRILLE <br /> E PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT. / / State Work Done <br /> PUMP REPAIR: _ / / State Work Done; <br /> DESTRUCTION OF WELL: Well. Diameter Approximate Depth <br /> Describe Material and Procedure <br /> f 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. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. -X0..7$ <br /> { SIGNED H_ENN_INGS BROS. DRILL- IN . , INC B Y TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR D PARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY al DATE a 3 7lf <br /> ADDITIONAL COMMENTS: el <br /> { PHASE JI GROUT ,INSPECTI PHASE III/FINAL. INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE f�Z <br /> _�.-ETH 1426 Rev. , 1-74 _ - <br />