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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazel0n'gVe. , Stockton, Calif. <br /> 3V Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7,7_167.4] <br /> A <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 ande Rules and Regulations of the San Joaquin Local Health District." ` <br /> X7771 'V7VV 2-u �o <br /> JOB ADDRESS/LOCATION Hwy 12p HARROLD RD. $NORTH_SIDE OF HWY 120CENSUS TRACT ' d <br /> f Owner's- Name ED,,IPEREIRA Phone 524-7591 <br /> k Address _ ....__ 704 SCENIC VIEW CT. _ City MODESTO <br /> t Contractor's Name HENNINGS I BROS. DRILLING CO. ,INC o License # 290813 Phone 522-1031 <br /> 2500 W.'i RUMBLE RD. 9 MOD <br /> F _ _ <br /> Y1?E .OF WORK (Check) : NEW WELL /X/ DEEPEN '/—/ RECONDITION /_/ DESTRUCTION /_T <br /> PUMP'•INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other. <br /> i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> 4 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 Excavation p <br /> Domestic/private Drilled Dia. of Well Casing 6t ,C3 .��Ti <br /> -�• =-Domestic/°public Driven-` Gau 6-of-Casing - ui�Gl'P�f •-_ <br /> ' Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection r X Rotary Type of Grout ArrrYu. <br /> Disposal t Other Other Information <br /> Geophysical. Surface Seal Installed By: <br /> PUMP INSTALLATION: Contracts" e64� <br /> Type of Primp H.P. <br /> PUMP REPLACEMENT: / / State Work Done..._ ` <br /> PUMP REPAIR: / / State Work Done <br /> - - r <br /> DESTRUCTION OF WELL: WellsDiameter Q App imate Depth <br /> x Describe r a lure <br /> lid Awl <br /> I hereby-agzee -to--cnmily with al laws and regu a ons of the San Jo uin Local Ifealth 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 the1well 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 ZOUTING ANPA FINAL INSPECTION. <br /> SIGNED : TITLE <br /> ! (DRAW T PLAN 'ON REVERSE SID <br /> OR WARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED DATE <br /> f ADDITIONAL COMMENTS: <br /> PHAJSE II ROT INSPECTI N PHAS I /F INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> 4H 1426 Rev. 2 j . <br />