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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF�lOFFIC_�USE: 1601 E. Hazelton Ave• , 'Stockton, Calif. <br /> Telephone: (209) 4666781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued1 -7-� I <br /> (Complete In Triplicate) . <br /> Application is hereby made to the San Joaquin Local Health bisttict 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/LOCATION 8650 South Wolfe Rd. French Campi Cal CENSUS TRACT <br /> Owner's Name Del_Auchg General Contractor Phone 835-2 93 <br /> Address 1369 Lincoln Blvd City Tracy, Cal. , <br /> Contractor's Name Hennings Bros. Drilling Co. , Inc . License # 290813 Phone 522-1031 l <br /> 25-O25-OQ West <br /> 4 <br /> ' 4 <br /> i <br /> TYPE OF WORK (Check): NEW WELL-/X7--DEEPEN '/77 RECONDITION'/? 'DESTRUCTION /_7 t <br /> PUMP INSTALLATION /—/ PUMP REPAIR / ./ PUMP REPLACEMENT <br /> * 1 <br /> other /_7 OU � <br /> DISTANCE TO NEAREST: SEPTIC TANK 1001 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER v `; <br /> PUBLIC DOMESTIC WELL <br /> INTENDED..IT..-..- -PRIVATE DOMESTIC WELL P _O <br /> PROPERTY LINE <br /> USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> 4 <br /> Industrial Cable Tool Dia. of Well Excavation n <br /> _ X Domestic/private -Drilled Dia: "of Well Casing <br /> •A Domestic/public r '` Diiven '3 '• Gauge of Casing ! t _ t <br /> Irrigation "f GravelhPack i Depth of Grout Seal t <br /> Cathodic Protection X Rotary.-' ° ,_7 Type of Grout <br /> Disposal Other Other Information-_ Slab b3� owner. <br /> Geophysical Surface Seal Installed BDriller <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: f_1 State Work Done <br /> : <br /> PUMP 'REPAIR: /_7 State Work Done <br /> FES•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 <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-beat of myknowledge and''belief., I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> ADjtAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ` <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II 0WWT SP ONPHASE III FINAL INSPECTION <br /> INSPECTION BY ATE INSPECTION BY DATE '?-/- <br /> E H 1426 Rev. 1-74 1-74 2M <br />