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g�,_) SAN JOAO'JIN LOCAL HEALTH DISTRICT <br /> FOP OYFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 26-//710 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7-11-76 <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 CHRISMAN RD. - MILE NORTH OF DELTA- CENSUS TRACT <br /> MENDOTA CANAL <br /> Owner's Name STEWART CLEVER Phone 835-2827 <br /> Address P 0 BOX 691 City TRACY, CAL <br /> Contractor's Name HENNINGS BROS. DRILLING CO. , INC. License # 290813 Phone 522-•031 <br /> AL. 95350-- <br /> a <br /> TYPE OF WORK (Check) : NEW WELL /XU' DEEPEN /_/ RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other /_/ <br /> DISTANCE TO NEAREST: SEPTIC TANK None SEWER LINES PIT PRIVY <br /> Future Home not SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> in PROPERTY LINE - PRIVATE DOMESTIC WELL— PUBLIC DOMESTIC WELL — <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 13" <br /> XX_ Domestic/private Drilled Dia. of Well Casing 81, <br /> Domestic/public Driven Gauge of Casing 10 Ga �`p\ <br /> Irrigation Gravel Pack Depth of Grout Seal 50t <br /> Cathodic Protection XX Rotary Type of Grout Bentonite r <br /> Disposal Other Other Information Slab by owner Q <br /> Geophysical Surface Seal Installed By: driller <br /> 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 /> 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 C24LL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED HENNINGS BROS. DRILLING CO. INC. TITLE BKPR <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 7- _ 7 �o <br /> ADDITIONAL COMMENTS: <br /> Ppag II jZ9UT INSPECT ON PHASE I/ AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYDATE <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />