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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOF OFFICE USE: ¢l 1601 E. Hazelton Ave. , Sto%Jkt. on, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7Z-#,6,51_j <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued S <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 Regulations of the San Joaquin Local Health District. <br /> c ENSUS TRACT <br /> JOB ADDRESS/LOCATION _7 <br /> 11 <br /> � hQ <br /> Owner's Name Milton Marlin Phone <br /> AddressP.O. Box 101 G 1� City Barites'" <br /> Contractor's Name He in S Bros. Drilling Co. Inc. License # 29081 Phone 522-10 1 <br /> 2500 W. Rumble Rd. mod. i <br /> TYPE OF WORK (Check) : NEW WELL /X/ DEEPEN/ / RECONDITION / / DESTRUCTION <br /> PUMP INST—ALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT 1_7 <br /> Other / / <br /> DISTANCE 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 1111 <br /> _ Domestic/private Drilled Dia. of Well Casing 11 V <br /> Domestic/public Driven Gauge of Casing 160 wall _ <br /> Irrigation Gravel Pack Depth of Grout Seal —5()l <br /> Cathodic Protection _�X e Rotary Type of Grout B <br /> Disposal �- <br /> Other Other Information Slab-by owner <br /> Geophysical Surface Seal Installed By: driller <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> b :P.UMP -r-REPAIR: / / State Work Done <br /> DESTRUCTION 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. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED HENNINGS BROS. DRILLING C INC. BY TITLE SEC' <br /> DRAW PIS T PLAN ON REVERSE SIDE ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA E II/ INAL INSPECTIO <br /> INSPECTION BY /'} Ci1J - DATE &-2.j 77 INSPECTION BY r" DATE 1177 <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />