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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OF ICE-JSE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> k APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �7tj <br /> i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <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 Reg tions of the San J aquin Local Health District. <br /> JOB ADDRESS/LOCATION . CENSUS TRACT <br /> Owner's Name .� Phone -5.0 <br /> Address c�r '7 City <br /> ' Contractor's Name HENNINGS BROS.. DRILLING Cog INC. License # 116322 phone522�-5 43 <br /> 2 00 W. <br /> RUMBLE. M. <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN /_� RECONDITION /_� DESTRUCTION /_7 - <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE a TYPE OF WELL <br /> CONSTRUCTION SPECIFICATIONS }r <br /> Industrial Cable Tool Dia. of Well Excavation !!�� <br /> Domestic/private Drilled Dia, of Well Casing %7. 0 <br /> Domestic/public ii Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout I <br /> Other Other Information — s <br /> PUMP INSTALLATION: Contractor <br /> Type-'of Pump H.P. <br /> F PUMP REPLACEMENT: /7 State Work Done <br /> PUMP REPAIR:{ /, /. _State Work Done„ <br /> .RESTRUCTION 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 Focal 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 /> HENNINGS BROS. DRILLING CO. , I�LUZ&NC <br /> SIGNEDTITLE BOOKKEEPER <br /> (DRA PLOT PLAN ON REVERSE SIDE <br /> FORZJ2 USE ONLY <br /> PHASE I !I 1 <br />� APPLICATION, ACCAr/ <br /> ADDITIONAL COMMENTS: - /J_ i ge DATE I: -7j <br /> PHASE II OUT INSPECTXON PHA E fIlLEINAL 'INSPECTION ' <br /> INSPECTION BY DATE 1F INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M � <br />