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SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> C0�'.70F ICE4JSE: 1601 E. Hazelton Ave. , Stockton, Calif. � <br /> Telephone: (209) 466-6781 r� <br /> 7 � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �{� g LJ � <br /> �.. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 8= c <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/LOCATION20281. El Rancho CENSUS TRACT. S4s <br /> 4 <br /> Owner's Name Bill $�'� �j/Qr Phone 835-1034 <br /> Address 20 1 E1 Rancho City Tracy, Calif. <br /> Contractor's Name BENNINGS BROS . DRILLING CO. INC* License #290813 Phone 522-1031 <br /> 2970--West Rd . Modesto Cal. 0: <br /> TYPE OF WORK (Check): NEW WELL/,V DEEPEN '/—/ RECONDITION /—/- DESTRUCTION /_7 <br /> PUMP INSTALLATION /% PUMP REPAIR /—/—PUMP REPLACEMENT I� <br /> - - - - Other / / - . . — <br /> STANCE TO NEAREST: SEPTIC TAINK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 1 In <br /> XDomestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 12 a ^ <br /> Irrigation Gravel. Pack Depth of Grout Seal 501 _ <br /> Other X_; Rotary Type of Grout - Bentonite ^ <br /> �- - --- Other tither Information Slab b owner ; <br /> t <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump -------- - - H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP •'tEPAIR: State-Work. Done- <br /> .DFATRUCTION 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. <br /> I <br /> SIGNED Q ' TITLE <br /> RAW PIAT PLAN ON REVERSE SIDE) <br /> FO DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTE $ - ' U5 DATE <br /> ADDITIONAL Come <br /> P OUT.-INSPECTION PHA$-EX P -EXINSPECTION <br /> INSPECTI N B <br /> �,DATF: INSPECTi{,11�3' Y DATE � 0- <br /> ' M <br /> CALL FOR A GROUT ;INSPECTION PRIOR'TO` GROUTING AND FINAL` 'INSPECTION.' V <br /> E H 1426 r�/711 <br />