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rlt�" 9 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: ,1601E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : . (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 73- to <br /> THIS PERMIT 'EXPIRES 1 YEAR FROM DATE ISSUED Date Issued �4�lQ-?3 <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 /> JOB ADDRESS/LOCATION CREMR AND MURPHYTRD. Z'`F,5-- l'90� <br /> CENSUS TRACT <br /> Owner's Name. ' FRANK, SANTOS , <br /> Phone 599--3282 <br /> Address P. 0. BOX <br /> 304 City <br /> Contractor's Name Hennings Bros. Drilling Co. , Inc. License # 116322 phone522.56 3 <br /> 2500 w. UM a 0 e o f <br /> .TYPE OF�WORK,.,(Check) .,..�NEW_._WELL -/,$/ - 1EEPEI+I -.�_� W _ <br /> r .Z: _�- r� RECONDITI°ONV /_�-DRSTPtiCTI�ON-/?' •�.- <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other L-1 6�e-� -- <br /> DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 22 ' <br /> Domestic/private Drilled Dia. of Well Casing rr <br /> Domestic/public Driven Gauge of Casing lEjrr <br /> llt Irrigation X Gravel Pack Depth of Grout Seal <br /> Aw <br /> Other _� Rotary Type of Grout 1 <br /> Other Other Information Slab By Owner <br /> t <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State WorkC Done <br /> DESTRUCTION OF WELL: Well Diameter ~ Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with allilaws 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 /> TELL DRILLERS REPORT of the well and notify them before putting the"well in use. The above <br /> Lnformation is true to the best of my knowledge and belief. <br /> sd. <br /> r <br /> SIGNED jTITLE <br /> (D W PLOT PLAN ON REVERSE SIDE <br />'HASE I FOR DEPARTMENT USE ONLY <br /> IPPLICATION ACCEPTED BY _ <br /> IDDITIONAL COMMENTS: DATE /207 ; <br /> PHASE II GROUT INSPECTION <br /> INSPECTION BY P E I 1;INAL INSPECTION <br /> DATE INSPECTION BY DATE / <br /> CALL FOR A GROUT INSPECTION ,PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 <br /> 7/72 1M <br />