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SAN JOAQUIN LOCAJ. W,6LTH DISTRICT <br /> FOFx�OFFICE USE. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209). 466-67$1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, 4� <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 Rulesend Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION ' <br /> U f - r.CENSUS TRACT <br /> Owner's Name �. 5 ).:phone ' -862-1816 <br /> Address 302.86 Ha 11 Rd. Cit <br /> Contractor's NameHennlne_q BrQq, DrIlling Co. ,Ine License V2208i Phone 522-1011 <br /> Rumble Rd. Mod. <br /> TYPE OF WORK (Check): NEW WELL A7 DEEPEN '/7 RECONDITION f7 DESTRUCTION /7 <br /> PUMP INSTALLATION '// PUMP REPAIR%'] PUMP REPLACEMENT., f_7/ <br /> Other / <br /> t.ti 9 <br /> DISTANCE TO NEAREST: SEPTIC TANK 3MI SEWER LINES _� PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT . T` OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL j � ! <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Irl <br /> Industrial Cable Tool Dia. of Well Excavation 11T,-- <br /> X Domestic/private. Drilled Dia. of Well Casing 611 Elastic <br /> Domestic/public — Driven Gauge of-,Cas1ng"^_ - 1-UO Wall <br /> Irrigation: ' Gravel Pack- Depth of Grout Seale O' <br /> Cathodic Protection X Rotary Type of Grout Bentonite. <br /> . Disposal Other Other Information _Slab b_y pwner <br /> Geophysical Surface Seal Installed �By: driller - <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump H.P, 1 <br /> PUMP REPLACEMENT: , / / State Work Done . . . <br /> PUMP' :REPAIR: /7 State Work Done <br /> DESTRUCTION OF WELL: Well, Diameter Approximate Depth <br /> Desc ibe Material and Procedure <br /> I hereby agree to comply with all law and regulations of a San JdAqtWn Local-Health Distr ct <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 4 <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-o€- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED .HENNINGS BROS. DR -INC. BY TITLE SEC. <br /> (V RAW PLOT PLAN ON REVERSE SIDE. <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> � � .. � <br /> APPLICATION ACCEPTED. By 4DATI�. <br /> ADDITIONAL COMMENTS "/— £ <br /> PHASE IIGROUT' INSPECTION <br /> PHASY, III AL IN <br /> INSPECTION BY DATESPECTIO <br /> ' INSPECTION. BY .. DATE fir- t <br /> E'H x4264 ��- <br />