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` '� '"' SAN JOAQUIN LOCAL HEALTH- DIS TRICT �cc�� <br /> F E OFFICE USE: 1601 E. Hazelton A-re. ,_-ilStockton, Calif. <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 1_1 <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. 1$62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> F <br /> JOB ADDRESS/LOCATION _17874 Stein ul Rd. _ mi North w CENSUS TRACT <br /> east side <br /> Owner's Name <br /> A.L. D ou las Phone <br /> Address 1 718 Center St. <br /> f city . <br /> Contractor's Name Henning s Bros. Drilling Co. Inc License # Phone � <br /> 2500 TrT. Rumble Rd. Mod. - 32�-LC1�1- <br /> ii <br /> TYPE OF WORK (Check) : NEW WELL A-1DEEPEN /_/ RECONDITION /_7 DESTRUCTION /7 <br /> PUMP.: INSTALLATION / / PUMP REPAIR '/ / ' PUMP REPLACEMENT /_7 <br /> Other J-7 I <br /> DISTANCE TO NEAREST: SEPTIC TANK i+ SEWER LINES PIT PRIVY.: <br /> SEWAGE DISPOSAL FIELD 6j2 CESSPOOL/SEEPAGE PIT OTHER - 6 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL _,,. CONSTRUCTION,SPECIFICATIONS <br /> Industrial <br /> �. Cable Tool Dia. of Well Excavation 11 n <br /> Domestic/private [ Drilled Dia. of Well Casing _ rr N-1 a <br /> Domestic/public ! Driven Gauge' of Casing <br /> Irrigation # Gravel Pack Depth of Grout Seal 50i i <br /> Cathodic Protection, FX Rotary Type of Grout Bentonite <br /> _ <br /> Disposal f Other Other Information— -'- <br /> Geophysical Sl - by <br /> Surface Seal Installed By: driller <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. 4 <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: / / State Work Done ` <br /> DES•TR_UCTION OF WELL: Well Diameter Approximate Depth <br /> Describ Mater 1 an Procedure <br /> I hereby tee o complyrare <br /> with all laws and regulations of the San Joaquin Local He th District r <br /> ,.nd the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on anew 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 CO. NC'. BY TITLE , <br /> 1 ,J DRAW PLOT PLAN ON RE FRSE SIDE) + <br /> r OR DEPARTMNTUSE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> P TI ROUT INSPECTIQN PHAS IT };FINAL INSPECTION <br /> INSPECTION BY DATE y 4 INSPECTIONrBY DATE <br /> E H 1426 Rev. 1-741&e l�4. r `: � .i '.f � /''/ �i11 3/76 2M <br />