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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 76—g!OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ` <br /> 'USE. _ <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 6---14-744"(Complete In 'Triplicate). I <br /> Applicatio"n 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 /> Count "Ordinance No. 1862 and the- Rules and Regulations ot 'the San Joaquin Local Health District. <br /> JOB�ADDRESS/LOCATION 9.50 We,91 Sneed Freneh Cain , rn1 _ CENSUS TRACT <br /> Owner's Name Del Auch, General Contractor Phone 835-2593 <br /> Address 1369 'Lincoln Blv'd - Y City Tracy, Cali, <br /> Contractor's Name Hennings Bros. Drilling Co . Inc. <br /> License # 290811 Phone 522-10U. -_ <br /> 2500 <br /> TYPE OF WORK (Check): r.NEW WELL -IK7 DEEPEN -/_7 RECONDITION /_7 DESTRUCTION r i <br /> PUMP INSTALLATION J / PUMP REPAIR /7 PUMP REPLACEMENT r7 <br /> Other <br /> (DISTANCE TO NEAREST: SEPTIC TANK 1101 SEWER LINES PIT PRIVY ( ^ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER v <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL �► <br /> INTENDED USE TYPE OF WELL _ � ' CONSTRUCTION SPECIFICATIONS # <br /> Industrial Cable Tool Dia. o£ -Well Excavation� <br /> Domestic/private Drilled Dia. of Well Casing <br /> tr X. Domestic/public Driven Gauge of Casing Ga— <br /> Irrigation <br /> _Irrigation Gravel Pack Depth of Grout Seal 50, <br /> Cathodic Protection X_ Rotary Type of Grout Bentonite <br /> Disposal Other Other Information Slab by aDWer <br /> Geophysical Surface Seal Installed By: drilleP <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump i . _ .�_.t H.P. <br /> PUMP REPLACEMENT: f_1 State Work Done X i <br /> PUMP '.REPAIR: /_7 State Work Done <br /> ,SES TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> .f <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 t <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 puttingthe -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 TQ GROUTING AND A FINAL INSPECTION. <br /> SIGNED "IV, rf: ` /P f v, s�s,�,�, TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY . DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE G ISP ION PHASE III_ZFINAI.IINSPECT10N <br /> INSPECTION BY DA INSPECTION BY DATE -�_7 <br /> 1 E H 1426 Rev. 1.-74 1-74 2M <br />