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SAN JOAQUIN LOCAL IWAL'TH DISTRICT <br /> FOFs:OI:FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP' PERMIT Permit No. ,7S--42_51ld <br /> F THIS PERMIT EXPIRES I, YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the Son 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 Joaquir <br /> County Ordinance No. 1$62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> t <br /> f OB ADDRESS/LOCATION /02 <br /> CENSUS TRACT S- 5 <br /> Owner's Name Casey-Schneider Phone $35-5466 <br /> Address 23034 Hanson Rd. City Tracy-2 Cal. <br /> I .Contractor's Name Hennings Bros . Drilling Co. , Inc", ! License # 9 2 Phone522-�0$13 031 <br />� - <br /> TYPE 4 WORK (Check) NEW 1WELL /YJ., DEEP.EN.# — _ ; <br /> _ ISTtECQNDITiON:. - DE�^x'RUCiON . <br />�� �� PUMP"INSTALLATION �/ pUMP REPAIR /_7 PUMP REPLACEMENT % f <br /> Other <br /> , t <br /> DISTANCE TO NEAREST: SEP TIC ".TANK 4O . SEWER LINES PIT PRIVY <br />'.X SEWAGE �DISPOSAL FIELD CESSP004/SE AGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial t Cable Tool Dia. of Well Excavation lr� <br /> XX Domestic/private � Drilled Dia. of Well Casing tr as t1. <br /> Domestic/public Driven Gauge of Casing W <br /> Irrigation _..�___ Gravel Pack. Depth of Grout .Seal <br /> Cathodic Protection - - Rotary Type of Grout Bentonite <br /> Disposal <br /> a <br /> Geophysical Other Other Information--""-- - Y owner <br /> Surface Seal Installed 'B r . . . <br /> PUMP. INSTALLATION: Contractor <br /> Type of .Pump <br /> H.P. <br /> PUMPREPLACEMENT <br /> . �/ State Work <br /> PUMP '.REPAIR: � <br /> . �/ / State Work Done • . <br /> DES-TRUCTION'-0F`WELI;: X11 Diamter <br /> Describe Material and Procedure Approximate Depth <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 /> GNED G <br /> TITLE <br /> DRAW PLOT 'PLAN ON REVERSE SIDE <br /> FOR DEP T T USE ONLY <br /> PHASE I <:APPLICATION ACCEPTED�BY DATE ' <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT 1NSPECTION MAO II NAL INSPECTION <br /> INSPECTION BY . , / DATE - �� INSPEC DATE - ZD- <br /> E H 1426 Rev. 1-74 r ,.... -- <br />