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SAN JOAQUIN LOCAL HEALZH DISTRICT <br /> —F6-r, OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> Telephone: (209) 466-6781 G� 7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No 0 cc1 <br /> _A THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued - 0CJ <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 Joaqu" I <br /> County Ordinance No. 1.862 and the Rules and Regulations of the San Joaquin Local Health District,) <br /> f.t.t -9;. 2-t 2-r717--15 <br /> JOB ADDRESS/LOCATION Larch Rd &c Trac �•M 1 00 t North of Larchw on - Tracy stls TRACT <br /> Owner's Name Pedro Degadillo Phone 835--3258 <br /> Address 21171 South Tracy Blvd City Tracy, Ca. j <br /> 290813 545-11$5 <br /> Contractor's Name Hennings Bros . Drilling Go. , Inc. License �� Phone <br /> 3525 Pelandale Ave. Modesto, Ga. 95350 _ I1 <br /> TYPE OF WORD (Check) : NEW WELL �Xl_ DEEPEN /_/ RECONDITION /_/ DESTRUCTION /_7 + <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_- T <br /> Other _-- i <br /> 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK 601 SEWER LINES t PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER j <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL 21 ' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation 12" <br /> XX Domestic/private XX Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 16 <br /> Irrigation Gravel Pack Depth of Grout Seal 50L <br /> Cathodic Protection XX Rotary Type of Grout Bentonite <br /> Disposal Other Other Information Slab by owner <br /> Geophysical Surface Seal Installed By : <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 /> z 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 WILA CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. By <br /> SIGNED Hennings Bros.-D- Dri1ling CT.--j Inc. TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br />'iAPPLICATION ACCEPTED BY IMP DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY C� r,3,DATE <br /> E H 1426 Rev. - I-74 <br />