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' - SAN JOAQUIN LOCF#47HEALTH DISTRICT <br /> FO <br /> _, F •OFFICE USE: ��j/// I! 1601 E. Hazelton Ave,. , Stockton, Calif. - <br /> Telephone : (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT :EXPIRES 1 YEAR FROM DATE ISSUED Date Issued � T <br /> 11 (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 workl.herein, described,. This application is made in compliance with San Joaquin <br /> County Ordinance., No. 18.62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> I <br /> JOB ADDRESS/LOCATION 2011$ S. Cedar Ave.. N of Hwy 205- off Berry RdCENSUS-TRACT <br /> Owner's Name A & A Dairy C/O Dane Alegre. a <br /> Phone $35-1035 <br /> Address 2011$ .S Cedar Ave. <br /> � City Tracy, Ca. <br /> Contractor's Name HENNINGS BROS. DRILLING CO. , INC. 290$13 545-11$5 <br /> 11 lj'jr� 11License # Phone <br /> 3 TO' 9534 <br /> ` <br /> TYPE OF WORK (Check), ; NEW WELL /�/ <br /> _ DEEPEN RECONDITION /_/ DESTRUCTION %� <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT G <br /> Other / fn <br /> ► 2 - - <br /> DISTANCE TO NEAREST: SEPTIC TANK AWSEWER LINES - PIT PRIVY <br /> SEWAGE DISP05AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL — PbBLIC DOMESTIC WELL <br /> INTENDED. USE , 0 TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation 121r <br /> Domestic/private ^~ � Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing; Sch e e aS RIC 4 <br /> Irrigation Gravel Pack Depth of Grout •Seal ,�� 's <br /> Cathodic Protection - Rotary Type of Grout <br /> Disposal06er Other Information Slab by owner <br /> Geophysical - Surface Seal Installed <br /> Dairy By: driller <br /> PUMP INSTALLATION: Contractor <br /> TYPe of Pump H.P.JI. - <br /> PUMP REPLACEMENT: / / State Work Done <br /> II <br /> PUMP REPAIR: hl/ State Work Done <br /> DESTRUCTION OF WELL: well Diameter Approximate Depth <br /> Describe Material and Procedure p <br /> I hereby agree to comply:4.4ith 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 thle best of my knowledge and belief. I WILL C FOR A GROUT INSPECTION <br /> PRIOR TO- GROUTING AND A FINAL INSPECTION. <br /> SIGNED HENVINGS B CO. , INC.. TITLE y - <br /> I 10 <br /> (DRAW PLOT PLAN ON.-REVERSE SIDE) <br /> ` FOR DEPARTME US`E''ONLY <br /> PHASE I li� <br /> APPLICATION'ACCEPTED BY Ir'� DATE ��r' <br /> ADDITIONAL COMMENTS: <br /> c P SE II, ROUT 1NSPEC ON <br /> P SE II /FINAL T SPECTION <br /> INSPECTAQ,N BY ATE - INSPECTION B <br /> ' <br /> E HX146 <br /> .,,. Rev. , 1-74 ✓ nf`l7 2M <br />