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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ' <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,.3-.3 FjS-A,) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued g&' -,;k- <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 Re lations the San Joaq n Loca a th District. <br /> JOB ADDRESS/LOCATION I b CENSU TRACT �7'S <br /> Owner's Name Phone <br /> Address City <br /> HENN NGS BROS. D LLING C ., !N <br /> Contractor's Name ff LLIZ. License # Phone - <br /> :e-')uu W. RUMBLE ROAD <br /> ll EN�$E 116322 <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /_/ RECONDITION /-7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELLONSTR P <br /> C UCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> 4---Domestic/private 4-- Drilled Dia. of Well Casing f d <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / J State Work Done ,. <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> 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. <br /> 7 <br /> SIGNED TITLE <br /> (D PLAN ON REVERSE SIDE <br /> OR D ARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPT DATE ��~�j—�� <br /> ADDITIONAL COMMENTS: <br /> S I GROUT INSPECTION PUM IjrIAKNAL INSPECTIO <br /> INSPECTION BYEA <br /> DATE a-- INSPEC N -- 4-- <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />