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` SAN JOAQUIN LOCAL: HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave.; •Scockton, Calif. <br /> . <br /> Telephone • (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -d_ 1O1b <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -7 /6 _ <br /> (Complete In Triplicate) <br /> j Appli6cafion is hereby made to the San Joaquin Local Health District for a permit to constru4`t ` <br /> and/or install. the. work herein described. This. application is made in compliance with San 'joaquin ! <br /> Coun}y Ordinance No. ,1862 and the ,Rules and Regulations of the San Joaquin Local Health District. <br /> Cor al. Hollow Rd. <br /> JOB ADDRESS/LOCATION 3/ mile north of Grant Line Rd. - West S' <br /> SUS TRACT . <br /> Owner's Name rTOSe G. BraYo , <br /> Phone 835-6764 <br /> Address •21$3$ S. Corral Hollow Rd.. <br /> City Tracy, CA. 95376l <br /> Contractor's Name HENNINGS BROS. DRILLING CO.. INC. <br /> � License # 294$13 Phorie 545-1185 W <br /> I <br /> 25 PELANDALE AVE. MODESTO, CA. 9 54 <br /> TYPE OF WORK (Check) : NEW WELL /Z/_ DEEPEN /_/ RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 C <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK 70t SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL 201 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS i.f <br /> Industrial Cable Tool Dia, of Well Excavation ll" <br /> X Domestic/private �X Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing 160W- <br /> Irrigation X Gravel Pack Depth of Grout Seal 50 <br /> Cathodic Protection X Rotary Type of Grout Bentonite <br /> Disposal Other Other Information slab b ' owner <br /> Geophysical Surface Seal Installed : 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 we11 '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 I <br /> information is true to the best of. my knowledge and belief. I WILL L FOR A GROUT INSPECTION ' <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED HENNINGS BROS. DRILLING CO. INC. LE <br /> (DRAW PLOT PLAN ON REVE SIDE) BK PR <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 7 <br /> DATE <br /> ADDITIONAL COMMENTS: <br /> PIIASII RpUy INSPECTION P E I' /FINAL INSPECTION <br /> INSPECTION B. E _- -1� INSPECTION BY DATE <br />• •4_E H 1426 Rev. . 1-'74 <br /> 6/%7 _ 2M <br />