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L�'1/ 1601t4 �SAN JOAQUIN LOCAL HEALTH DISTRICTFOF,iOFFICE USE: E. Hazelton Ave. , Stockton, Calif. <br /> Telephone (209). 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. (7 <br /> THIS PERMIT EXPIRES 1 YEAR ..FROM DATE 'ISSUED Date Issued <br /> (Complete InTriplicat.e) Y <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 i.s.. made in;[compiiance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and. Regulations o€ the Sari -Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION IMRLEN ED I ZAST OF FREEWAY,APROX. 28001- f CENSUS TRACT <br /> EAST OF HARLEN 14001 NORTH OF SQUIRES RD:,NEAR . P TBACK <br /> Owner's Name MIDDLE K FARMS .: CI�RIS LEWIS Phone , 92. .1 1 <br /> Address 112644. S. HARLEN _RD. iG city LATHR-OP . <br /> Contractor's Name HENNINGS BROS. DRILLING CO. INC. License # 290813 Phone - 522-1031 <br /> 25QO W, RUMBLE D MOD . .It <br /> TYPE OF WORK (Check): NEW WELL -9 j DEEPEN /_7 RECONDITION �_j DESTRUCTION f-7 <br /> PUMP INSTALLATION/ j PUMP REPAIR /� PUMP REPLACEMENT /? <br /> Other E7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ii a <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER &70,1 ; <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 p�+� <br /> Domestic/private Drilled Dia. of Well Casing . -_ � �� �\ <br /> Domestic/public Driven Gauge of Casing _ __ .3�1�� <br /> Irrigation _ Gravel Pack Depth of Grout Seal', . , <br /> Cathodic Protection ; Rotary Type of Grout <br /> Disposal Other Other Information 17�h_ 11; nwnpr <br /> Geophysical Surface Seal Installed 'B <br /> PUMP INSTALLATION: Contractor v <br /> Type .of Pump H.P. <br /> y <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP REPAIR: /_ .State Work Done <br /> DES-TRUCTION 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 C_A_LL 'FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED G CO. INC. BY TITLE 'I SEC. <br /> DRAW PLOT PLAN ON REVERSE SIDE it <br /> FOR DEPARTMENT USE ONLY <br /> PHASE i iF <br /> APPLICATION ACCEPTED BY 4 DATE ' / <br /> ADDITIONAL COMMENTS: it <br /> PHASE II GROUT INSPECTION PHASEJ21fFINALfINSPECTION <br /> INSPECTION BY Al DATE <br /> IrN.S/ ON BY <br /> Y <br /> .. - E <br /> s Y/o < /M <br /> r <br />