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_ SAN JOAQUIN LOCAL. HEALTH DISTRICT ; <br /> FOF: OFFICE USE: 1601 E. Hazelton Ave. , ,Stoekton, Calif. <br /> _ Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. /.. _C� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUER Date Issued/--4Z--.V <br /> ' (Complete In Triplicate) <br /> Application is $ereby made7to 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 i <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. f <br /> JOB ADDRESS/LOCATION 2 CENSUS TRACT ' <br /> Owner's Name ��� ,sy!' !�!�/may Phone <br /> j <br /> Address City , � <br /> Contractor's NameHENNINGS BRRS. DRILLING CO. , <br /> INC. License #290$1 _ Phone 545-1185 <br /> _ <br /> TYPE OF WORK (Check) : NEW WELL &_7 DEEPEN / / RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK, - SEWER LINES PIT PRIVY ,; I <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER I <br /> PROPERTY' LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS j <br /> Industrial Cable Tool Dia. o£ 'Well Excavation 111r <br /> X Domestic/private Drilled Dia. of Well Casing 611 _ <br /> Domestic/public Driven Gauge of Casing I 00W <br /> Irrigation - - „ _,' - Gravel Pack ,'Depth of Grout Seal.;-.. 50t" . - - _ <br /> Cathodic Protection _ Rotary Type of Grout } <br /> RFN`i'nNTTF I <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: _ _ <br /> PUMP INSTALLATION: Contractor t <br /> Type of[ Pump H.P. f <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR• J Jt.;State -Work Done - •-�- -� t. -- <br /> DESTRUCTION 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 bistrict <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 4 <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 j <br /> PRIOR TO GROUTING AND A FINAL INSPECTION: <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I IF <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION ?HASEj4a1NAL INS PE TION 1 <br /> INSPECTION BY DATE f - INSPECTION BY DATE 7 <br /> /77 <br /> E H 1426 Rev. -74 "� _ • ...----- <br />