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M <br /> '5. ✓ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. y -f <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /6-.2- <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 with San Joaquin <br /> County Ordin nce No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 1149 <br /> �9 2 J S,�c�oat-•-- �,,�,-�,ev�' - �''� his F- Ps�b r •C�TH�dp <br /> JOB ADDRESS/LOCATION 60. DAJ 6/1STJAl /20. CENSUS TRACT <br /> Owner's Name A.ws -52r► 1rei Phone <br /> Address A02, city <br /> HENNINGS BROS. DRILLNG CO., <br /> Contractor's Name License # Phone <br /> mWiDESTMO CAM. <br /> TYPE OF WORK (Check) : NEW WELL V DEEPEN/ / RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION /�/ PUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> XSEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 2 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 's <br /> X_ Irrigation Gravel Pack Depth of Grout Seal C <br /> Other XRotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <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 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 /> SIGNED TITLE <br /> PLOT PLAN ON REVERSE SIDE <br /> r FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY � , � DATE 9-• f�Z� <br /> ADDITIONAL COMMENTS: <br /> PHASE,,II GROUT INSPECTION PHASE III/FTNAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ..... DATE Z <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br />