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a SAN JOAQUIN LOCAL HEALTH DISTRICT , <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> p 6 7 7 •, Telephone: (209) 466-6781 <br /> T` APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. / <br /> �7 THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued /�7 7 <br /> (Complete In Triplicate) <br /> Application is ne`reby 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 /> (S�- �� 0/S <br /> JOB ADDRESS/LOCATION 1$1+00 ENTERPRISE RD.-N.E. CORNER OF HWY 120 CENSUS TRACT <br /> & ENTERPRISE RD. <br /> Owner's Name M.J. MAC WILLIAMSON Phone 415-967-8681 <br /> Address P.O. BOX 189 city -MT. VIEW, CA . <br /> Contractor's Name HENNINGS BROS. DRILLING CO. ,INC. License # 290813 Phone 4 "--118 <br /> 2 PELANDALE AVE.3 MOD. <br /> a <br /> e _ <br /> TYPE OF WORK (Check) : NEW WELL / j DEEPEN /—/ RECONDITION /_/ DESTRUCTION 1-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT j7 <br /> Other <br /> D STANCE TO NEAREST: SEPTIC TANK SEWER LINES c2Q I PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER G)ELL-180 t <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 tr N. <br /> X Domestic/private Drilled Dia, of Well Casing $_5/$« _ <br /> Domestic/public Driven Gauge of Casing 1Q GA <br /> )( Irrigation Gravel Pack Depth of Grout Seal 501 <br /> Cathodic Protection X Rotary Type of Grout e" T _ <br /> Disposal Other Other Information 1 <br /> Geophysica] Surface Seal Installed B driller <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done - <br /> Z <br /> Rm4escg <br /> to Work Done C d L. P ��{.�-. 17>lz J 77meter / �/�7Approximate Depth <br /> Material and Procedure 16 <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 wi114furnish 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.' I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED HENNINGS BROS. DRILLING C 0. INC . BY TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I '�-/S- 7? <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> P GROt4t INSPECTI N PRASE IJI/FINAJC INSPECTION <br /> INSPECTION BY INSPECTION BY DATE <br /> f <br /> U0 W-co SO — 1777. . <br /> E H 1426 Rev. 1-74 <br />