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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. d <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED_ Date Issued 70 <br /> r (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 /> JOB ADDRESS/LOCATION 11203 W. VALPICO A CENSUS TRACT <br /> Owner's Name DEL AUCH Phone 835- 59L__ <br /> Address 1369 LINCOLN BLVD. City TRACY <br /> Contractor's Name HENNINGS BROS. DRILLING CO. JNC. License # 290813 Phone5�+5-1 185 <br /> a <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN_/ / RECONDITION / / DESTRUCTION /7 W <br /> PUMP INSTALLATION / / PUMP REPAIR j _/ PUMP REPLACEMENT /_7 <br /> Other /X/ HEAT PUMP WELL _ <br /> DISTANCE TO NEAREST: SEPTIC TANK 1_25 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 12 f 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 lilt <br /> X Domestic/private Drilled Dia, of Well Casing 6" plastic <br /> Domestic/public Driven Gauge of Casing 160 wall <br /> Irrigation Gravel Pack Depth of Grout Seal _ 01 <br /> Cathodic Protection X 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 BRO . BYTITLE SEC. <br /> (DIRAW PLOT PLAN ON RE SE SIDE) <br /> FOR DEPARTMENT YgE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY .eq DATE :2. / <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA E ITI FINAL INSPECTION <br /> INSPECTION BY i DATE INSPECTION BY DATE <br /> b/77 2M <br /> E H 1426 Rev. - I-74 <br /> _ <br />