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,i IT, <br /> �} SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL 'CONSTRUCTION OR PUMP PERMIT Permit No,17 <br /> IS PERMIT PERMIT EXPIRES 1 YEAR FROM DATEISSUED Date Issued I/./3-JZ <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 Joaqui <br /> F County Ordinance No. 1$6 and' the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 1 2 ouf-h Corral Hollow Trac Cal, CENSUS TRACT <br /> xousE <br /> 835-8513 <br /> Owner's Name r'_CLARENCE� SILVEIRA Phone SHOP 835-5207_ <br /> Address 19123 SOUTH CORRAL HOLLOW TRACY, CALIF. City TRACY, CALIF. <br /> Contractor's Name HENNINGS BBOS. DRILLING CO .t_ INC. License x.16 22 Phone <br /> TYPE OF WORK (Check): NEW WELL /X-1 DEEPEN /_/ RECONDITION /7 DESTRUCTION /7 <br /> f PUMP INSTALLATION /—/ PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> i <br /> Other <br /> ` DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> J� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION--SPECIFICATIONS <br /> Industrial Cable Tool Dia. o_f_Well Excavation <br /> � X Domestic/private Drilled Di of Well Cas "ing rr -b <br /> Domestic/public Driven Gauge of Casing ", <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other X Rotary Type of Grout � - v; <br /> Other Other Information <br /> � 1 <br /> PUMP INSTALLATION: J l3� ALL L <br /> Contractor 1 <br /> Type of Pump \Z H.p. P <br /> i PUMP REPLACEMENT- State Work bone <br /> F <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 o`+f-the-San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> fiafter 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 /> x <br /> SIGNED v TITLE <br /> D P 0q&VVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE// <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY /j DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTI 1� <br /> E H 1426' 7/72 1M <br />