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` SAN-JOAQUIN LOCAL HEALTH DISTRICT <br /> FO ;OFFICE USE: 1601 E. Hazelton Ane.,- sAtockton, Calif. <br /> Telephone:. (209) 466-6781 <br /> f APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7J <br /> THISPERMITEXPIRES 1 YEAR FROM DATE ISSUED Date Issued -Q=.�- ZS' <br /> (Complete In Triplicate) <br /> 4 Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> t 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+r <br /> CABMNTER� RD .�& POCK LANE-1 MILE WEST OF CENSUS TRACT <br /> HWY 99.7 SOUTH SIDE OF CARPENTER RD. <br /> Owner's Name HARRY SHREVE Phone <br /> Address r 1 6982' -HINTON ST. City CASTRO VALLEY <br /> Contractor's Name BENNINGS BROS. DRILLING 'CO-.,INC . License # 290813Phone 5-118 <br /> + 1525 PELANDALE AVE.3 MODESTO, CA. 953 50 <br /> l TYPE OF WORK (Check) : NEW WELL / DEEPEN '/_/ RECONDITION /_7 DESTRUCTION /_ <br /> F PUMP INSTALLATION / f PUMP REPAIR / / PUMP REPLACEMENT <br /> Other ! ! <br /> DISTANCE TO NEAREST: SEPTIC TANK 1101+ SEWER LINES PIT PRIVY <br /> i SEWAGE DISPOSAL FIELD 11 ()t CESSPOOL/SEEPAGE PIT OTHERWEjji_,2 Ct <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL ____ PUBLIC DOMESTIC WELL <br /> t INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 11:1 <br /> 7 X Domestic/private Drilled Dia. of Well Casing _ " PLASTIC <br /> Domestic/public Driven Gauge of Casing 160 WALL. <br /> Irrigation X Gravel Pack Depth of Grout Seal Sot <br /> Cathodic Protection X _ Rotary Type of Grout BENT ON ITE <br /> Disposal Other Other Information SLAB-BY OWNER <br /> Geophysical Surface Seal Installed By: DRILLER <br /> E PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> K PUMP,�.REPAIR: - ------ <br /> State "Work Done` <br /> DESTRUCTION OF WELL: We11. Diameter Approximate Depth <br /> Describe Material and Procedure <br /> j I hereby agree to comply with all Jaws 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 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 TO GROUTING AND A FINAL INSPECTION. ' <br /> i -20_78 <br /> SIGNED HENNINGS BROS. DRILLING ., INC. B Y TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> - FOR D ARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE __Leh) 3 ?e <br /> ADDITIONAL COMMENTS: <br /> PHASE I GROUT INSPECTION PHASE III/FINE INSPECTION <br /> INSPECTION BY DATE TJ7 INSPECTION BY DATE <br /> . ii!77 •��p M <br /> E H 1426 Rev. , 1-74 - <br />