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- S'AN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL OFFICE USE: �� J 1601 E. Hazel -o Ave. ,- Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERT. Permit No. Z6-S.So,2- 4,rJ <br /> THIS PERMITEXPIRES 1 YEAR FROM DATE ISSUED Date Issued $$-y-7 6 <br /> (Complete In Triplicate) <br /> Application is hereby trade 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 /> JOB ADDRESS/LOCATION 23075 SO. HANSEN RD. TRACY CENSUS TRACT <br /> Owner's Name CLYDE,.BUCHANAN Phone 415-447-2849 <br /> Address <br /> 140 DIAMOND DRIVE City LIVERMORE3 CAL. <br /> Contractor's Name HENNIN.GS BROS. DRILLING CO. , INC . License f)290$x-3 Phone 522-1031 <br /> 2500 E_ <br /> 4 f <br /> ` ��•m X16 .. ,,,,�„�.,.� <br /> TYPE OF WORK (Check) : NEW WELL /X DEEPEN '- .. // , PRECONDITION J DESTRUCTION47 <br /> "PUMP'"INSTALIATION e._-,, PUMP"REPAIR CEMEN"/-/--PUMP"'REPIAT 1_7 <br /> i if <br /> Other / J <br /> DISTANCE TO 'NEAREST: SEPTIC TANK- SEWER LINES PIT PRIVY , '° •.`` "� <br /> SEWAGE DISPOSAL-FIELD CESSPOOL/SEEPAGE P'I�Tsl OTHER <br /> `------!._ a PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL L <br /> INTENDED USE' TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> J:L 3T <br /> >Industrial ` Cable Tool- . Dia. of Well. Excavation` <br /> XX tDomestidforivate Drilled Dia. of Well CasingPlastic <br /> 1Domestic/pubAc . Driven Gauge-of_ Casing. <br /> {Irrigation Gravel Pack Depth of Grout Seal j� <br /> ;Cathodic Protection Rotary Type of Grout beIl Onl <br /> :Disposal Other Other Information ' -6.lao Dy owner <br /> :Geophysical Surface Seal Installed :, driller <br /> PUMP INSTALLATION: Contractor. " <br /> } Type of Pump t a H.P. <br /> PUMP REPLACEMENT: / / State Work Done ' <br /> r N: <br /> PUMP .REPAIR: J / State Work Done �� ► <br /> I DESTRUCTION OF WELL: Well Diameter . v Approximate Depth t <br /> t Describe Material and Procedure / <br /> I hereby agree to comply with all laws and regulations of _the-:San Joaquin.TLo.ca1__Health-Districtr.. <br /> and'te Ste <br /> at -of California pertaining to or regulating well '-construction.t Within FIFTEEN DAYS <br /> after. completion of my work on a new well, I will furnish the San Joaquin ,Local Health District <br /> WELL DRILLERS REPORT of the well and notify them before putting the -well in use. The above <br /> 1y, information is true to the best of my knowledge and belief. I WILL QkLL FOR A GROUT INSPECTION <br /> �' PRIOR,TO GROUTING. AND A FINAL INSPECTION. BY: <br /> :°SIGNED HENNINGS BROS. -DRILLING, C INC ... TITLE. //GLV BKPR <br /> DRAW PLOT' PLAN ON RE RSE SIDE <br /> F9& DEPARTMENT USE ONLY <br /> � PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ! ADDITIONAL COMMENTS: <br /> PHASE II GPIQUT INSPECTION PHASE III/FINO INSPECTION <br /> INSPECTION BY ' DATE INSPECTION BY DATE <br /> F:z /6 2M <br /> E H 1426 Rev. 1-74 = � <br />