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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 42 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 _w11,17 0 <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 /> WELL #1E <br /> JOB ADDRESS/LOCATION AIRPORT WAY— 1MILE NORTH OF FRENCH CAMP RD. CENSUS TRACT <br /> ELS T SIDE <br /> Owner's Name Stockton East Water District: Phone <br /> Address 2526 E. Fremont St. City Stockton <br /> Contractor's Name Hennings Bros . Drilling Co.,Inc. License # 290813 Phone 545-1185 <br /> 3525 Pelandale Ave. , Modesto <br /> TYPE OF WORK (Check) : NEW WELL/X/ DEEPEN / / RECONDITION /_/ DESTRUCTION /_ <br /> AL ` <br /> PUMP INSTLATION REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK NONE SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER WELL-V1 0 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL MILE <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation Pjgt 9'' <br /> Domestic/private Drilled Dia. of Well Casing 14" � <br /> Domestic/public Driven Gauge of Casing IGA <br /> Irrigation Gravel Pack Depth of Grout Seal 180' <br /> Cathodic Protection Rotary Type of Grout Cement-9 sack m X �- <br /> -Disposal X Other Reverse Other Information Slab-by owner <br /> Geophysical Rotary Surface Seal Installed By: driller <br /> X Municipal <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. DRILLING C . ,INC. BY TITLE n c SEC. <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY __ �' DATE <br /> ADDITIONAL COMMENTS: 42 <br /> PHASE II GROUT INSPECZvlrt <br /> PHASE III/FINAL INSPECTION <br /> INSPECTION BY �1 DATE _ INSPECTION BY DATE <br /> 4,ccia„ <br /> E H 1426 Rev. - I-74 °'�77 _ 2M <br />