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SAN JOAQUIN_d,OCAL HEALTH DISTRICT <br /> TiO_R"OFFICE USE: -- <br /> 1601-E-. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 75- 2/k7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> 9pplication 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 /> :ounty Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> !-1 Si 2- . L­0-)�E- `MSF_P D -z 3- C`?e a� <br /> TOB ADDRESS/LOCATION FRENCH CAMP RD._1/BriI E. OF JACKmONE RD.- CENSUS TRACT <br /> NORTH SIDE <br /> timer's Name pRm vnN rzznnTTnrGEN _- — — Phone 599-3886 <br /> lddress 20828 JAr.KTONF. RD City RTI?()71T N <br /> ,ontractor's Name Hennings Bros . Drilling Co .Ins License # 29081 Phone 2„1031 f <br /> 2 00 W. Rumble Rd. Modesto' <br /> YPE OF WORK (Check) : NEW WELL, /X-7 DEEPEN /7 RECONDITION /_7 DESTRUCTION r <br /> PUMP INSTALLATION /—/ PUMP REPAIR/7 PUMP REPLACEMENT <br /> Other <br /> )ISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL — <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation 24" <br /> Domestic/private Drilled Dia, of Well Casing 16" <br /> Domestic/public Driven Gauge of Casing V1611 <br /> X Irrigation _x Gravel Pack Depth of Grout Seal none <br /> Cathodic Protection _� Rotary Type o£ Grout none <br /> Disposal Other Other Information Slab by owner <br /> _Geophysical Surface Seal Installed B Mry}3,X <br /> UMP INSTALLATION: Contractor <br /> Type of Pump H P <br /> UMP REPLACEMENT / / State Work Done <br /> �UMP '.REPAIR: /7 State Work Done <br /> ES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the—'San Joaquin Local Health District <br /> nd the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> fter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> ELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> nformation is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> 1IOR TO GIWUTINQ AND !FINAL INSPECTION <br /> IGNED J F ce TITLE <br /> W PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> RASE I <br /> PPLICATION ACCEPTED BY b, ( DATE <br /> MITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> -ISPECTION BY DATE INSPECTION BY - DATE <br /> E H 1426 Rc„ i_7A �•• <br />