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' ( SAN JOAQUIN LOCAL HEALTH DISTRICT F <br /> f <br /> F0_S;OFFICE USE: 1601 E. Hazelton Ave. ; Stockton, Calif. <br /> Telephone;: 7e'-PZ'� <br /> . p {2pg} 466-6781 <br /> APPLICATION FOR-WELL CONSTRUCTION OR PUMP PERMIT Permit No. 5-- <br /> f. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED. Date Issued Z2.-3-fr <br /> (Complete In Triplicate) <br /> Application is hereby made to the. San Joaquin Local Health Distriet. for.a permit to construct <br /> and/or 'install the work herein described. This application is made in compliance with San Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the Saar Joaquin Local Health District. <br /> f ). Trac <br /> .SOB ADDRESS/LOCATION '7� `. R��z�� `" 9-�� y CENSUS TRACT <br /> 4 <br /> Owner's Name CASEY SCHNEIDER, BLDR. ,� S-§.A /7 o Phone 835--0444 <br /> r Address 23034 SO. HANSEN RD`. ' City ' TRACY, CAL. <br /> Contractor's Name HENNINGS BROS. DRILLING CO. ' INC License 890$13Phone 522-1031 <br /> -_2 00-Lest.-Rumble. Rd_..,Modes to .,.:Cal. 95,350_ <br /> TYPE OF WORK (Check); NEW WELL -/X7 DEEPEN -/7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PLS REPAIR '/ / PUMP REPLACEMENT /_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY. <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL ' " 'PUBLIC DOMESTIC WELL <br /> f INTENDED USE TYPE OF WELL CONSTRUCTIDN 'SPECIFICATIONS - <br /> Industrial Cable Tool Dia. of Well Excavation 'r <br /> K X Domestic/private _7_ Drilled Dia. of Well Casing 4T <br /> Domestic/public Driven Gauge of Casing Plas Eic <br /> Irrigation Gravel Pack Depth of Grout Seal 501 <br /> Cathodic Protection --T--'Rotary Type of Grout t t . <br /> F Disposal _ Other Other Information b1bb by ownerpD <br /> Geophysical - - Surface Seal Installed By: 'driller ' - I <br /> PUMP INSTALLATION Contractor <br /> Type of Pump H.P. • <br /> !'PUMP REPLACEMENT: . ET State Work Done <br /> PUMP`'.REPA -..-.. <br /> IR= /� /A'`State o k Dane <br /> TRUCTION 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 l <br /> and the State of California pertaining to or regulating well"construction. Within FIFTEEN DAYS 6 <br /> after completion of my work on anew well, I will furnish the San Joaquin Local Health District W <br /> WELL DRILLERS REPORT of the well and notify them before putting.. the..well. in.use.... .The above d <br /> information is true -to the•best -of. my knowledge and belief. I WIL CALL FOR A GRO INSPECTION <br /> PRIOR TO GROUTING AND A- FINAL INSPECTI N. <br /> SIGNED hENNINUb bhUb . Aj t tu.,, INC. TITL 4-- �`� BKPR-SECTrY <br /> RAW PLOT AN ON REVERSE_SIDE <br /> R EP TMENT USE ONLY <br /> ` PHASE Ifj <br /> APPLICATION' ACCEPTEDB. DATE <br /> ADDITIONAL 7S <br /> COMMENTS: `. <br /> PHASE II GROUT INSPECTION PHASE IIT FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION. 'BY DATE 3 ? <br /> E H 1426 Rev. 1-74 _ ;h/7-5;,., 2M <br />