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I <br /> � . SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> FOR§'OFFICE USE: 1601 E. Hazelton Ave:, Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 �17a fc� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date' Issued //l7 7.5! <br /> (Complete In Triplicate) <br /> Application is hereby made to the Sam 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 Re. tions of the San Joaquin Local Health District. <br /> � �c . <br /> .TOB ADDRESS/LOCA �_ADDRESS/LOCATION. � � � CENSUS -TRACT ' <br /> OwneP°s NamePhone __t <br /> Address City <br /> Contractor's Name Hannings Bros. Drilling -Co._j Inc.. License 4# 220813 Phone 5221031 <br /> 2500 X. Rumhle Rd-o ode to <br /> r <br /> TYPE1OF WORK (Check) : NEW WELL DEEPEN /-7 RECONDITION /-7 DESTRUCTION / j <br /> PUMP INS AL TION /—/ PUMP REPAIR /-7 PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 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 Excavation6 `� <br /> 4 Domestic/private t--Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation . Gravel Pack Depth of Grout Seal <br /> Cathodic Protection v- Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP,iREPAIR: /7 State Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth y <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 .i.s 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 TITLE Zj sec-0 <br /> DRAW PLOT PLAN ON REVERSE SIDE11 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1,'. " <br /> APPLICATION� ACCEPTED BYys DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE 11-GROUT INSPECTION P SE FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BYADATE l- S <br /> + E;H 1426 Rev. 1-74 i 1-74 2M <br /> - - _ <br />