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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0 OFFICE USE.- 1601 E. Hazelton Ave, , StG•ckton, Calif. <br /> j w Telephone:. (209) 466--6781 l <br /> I APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. pg' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,gS 7sr' <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 compliance with San Joaquin <br /> County Ordinance No. ,1862 and the- Rules and Regulations of the San Joaquin Local Health. District. <br /> .TOB ADDRE5S/40CATION <br /> 1$_ WATERLOO FfNSUS TRACT <br /> _ 25 BEYER___LANE-1 MILE SOUTH OF WATE RD� <br /> _ W <br /> WEST SIDE <br /> Owner's Name RICHARD MEYERS Phone 823-3 .26:. r <br /> Addres's :.1825 - X BEYER LANE City STOCKTON <br /> Contractor's Name HENNINGS BROS. DRILLING CO. INC. License # 290813 Phone 545-1185 <br /> 352 • 7 <br /> TYPE OF WORK (Check) : NEW WELL /X/ DEEPEN '/ ./ RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 Qr <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANKED SEWER LINES PIT PRIVY ��- <br /> SEWAGE DISPOSAL FIELD4- 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 11"` <br /> X Domestic/private Drilled Dia. of Well Casing " PUTIC <br /> Domestic/public Driven Gauge of Casing 160 WALL � <br /> Irrigation X Gravel Pack Depth of Grout SealOt i <br /> Cathodic Protection Rotary Type of Grout BENTONITE <br /> Disposal Other Other Information SLAB-BY OWNER <br /> Geophysical Surface Seal Installed By: DRILLER <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. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION <br /> SIGNED HENNINGS BROS. BY TITLE SEC'. <br /> (DRAW PLOT PLAN IN REVERSE SIDE) <br /> F04 DEPAR NT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY u/� DATE <br /> ADDITIONAL COMMENTS: <br /> PHASZ II GROUT INSPECTION PHASE/, I INAI, INSPECTION <br /> INSPECTION BY DATE /0-7--7'8 INSPECTION B DATE 1,9-'Z-- <br /> L7 <br /> O-' - � <br /> E H 1426 Rev. - 1-74 <br /> b/77 _ 2M <br />