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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE�U;SE 1641 E. Hazelton Ave. , •Stockton, Calif. <br /> Telephone: (209) 466-6781 ��� <br /> ' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 <br /> I Q THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ' T (Complete In Triplicate) <br /> Application is tereby 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. .18b2 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 4 �s a CZ e� - : ,4,0A) : 2Zo3-- <br /> JOB ADDRESS/LOCATIONH0TJ; RD. z$ ,MTT;F FAST Q SOUTH- SIDE <br /> � CENSUS TRACT <br /> '- <br /> Owner's Name CHARLES ELS HOLZ Phone <br /> 16 X20 <br /> Address ;I S. MURPHY RD. City F_qt AT.njq <br /> Contractor's Name HENNINOS BROS. DRILLING License # j3Phone <br /> 2 PELA D A ' ' <br /> TYPE OF WORK (Check) ; NEW WELL DEEPEN /_/ RECONDITION / / DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES PIT PRIVY <br /> ii tC� <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation ;)(n <br /> Domestic/private Drilled Dia. of Well Casing 16" <br /> Domestic/public Driven Gauge of Casing <br /> X Irrigation ^y Gravel Pack Depth of Grout Seal <br /> Cathodic;lProtection _X Rotary Type of Grout <br /> Disposal Other Other Information SLAB-EX OW P-P <br /> Geophysical Surface Seal Installed BY: Yx <br /> A� <br /> PUMP INSTALLATION: Contractor <br /> TYp e. o f, Pump. _ . , . _ _.T_ . _ --H.P. <br /> PUMP REPLACEM!'NT: __ 'State Work.Done - - <br /> r �. <br /> PUMP '.REPAIR- / / State Work Done <br /> DESTRUCTION OF, <br /> 1 WELL: Well Diameter Approximate Depth"' - <br /> Describe Material and Procedure <br /> I <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 com`pletillon 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;ltrue to the best of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR-T0' GROUTING AND A FINAL INSPECTION. <br /> SIGNET). - `` IMENNING B --- TITLE SEC <br /> f <br /> (DRAW PLOT PLAN ON_ErRRSE SIDE) <br /> FOR DEPARTMENT VSE ONLY <br /> PHASE I _ <br /> APPLICATION ACCEPTED BY (/v DATE / /, <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE, Ilk/FINAIL INSPECT ON <br /> INSPECTION BY DATE - INSPECTION BY DATE i <br /> F. N 7A7F, In2M <br /> o„ �_7i. , 1177. _ 'f// <br />