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. f Y <br /> F <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR:OFFICE USE: ' <br /> 601 E. Hazelton Ave <br /> . , Stockton, Calif. <br /> ± . '° Telephone: .(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 9151/ <br /> THIS PERMIT EXPIRES l 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 187,2 and he ule and Mations of a San Joaquin Local Health District. <br /> 3 -: <br /> JOB ADDRESS/LOCAT)i0i 600f West of Jacktone lid. 0 Dosite, Clinjt n_ SUS TRACT GG <br /> Owner's Name /Jake Kam s Phone 699-7579 <br /> Address 21123' 3. Jacktone Rd. City ' PQn, Calif, <br />,Contractor' Name Hennings Bras Drilling Co. , Ine . License #290813 Phone 522v1031 <br /> A. <br /> West um e Rd. Modesto; a if. : 95354 • ; <br /> TYPE OF WORK (Check): NEW WELL 'XV DEEPEN '/7 RECONDITION f7 DESTRUCTION f7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/_7 PUMP REPLACEMENT 17 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK= SEWER LINES PIT PRIVY <br /> f. SEWAGE DISPOSAL"'FIELD CESSPOOL/SEEPAGE PIT OTHER 4 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL 4Qgt PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 24" <br /> Domestic/private ' Drilled Dia. of Well Casing l n x 1 <br /> Domestic/public. k Driven w.a =LGauge f-LCasing }= -:-3116. <br /> -�Krrigatn ,. = = ' -Grave Packer=?Depth of Grout Seal: -- �-. <br /> Cathodic Protection XX Rotary Type of Grout ' <br /> Disposal Other Other Information ' Sla b by gwner <br /> Geophysical Surface Seal Installed By:. <br /> PUMP INSTALLATION: Contractor'- <br /> Type <br /> ontractorType of Pump H.P. <br /> L � <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP 'REPATR: /7 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 thea before putting.the."well. in.use.... .The above <br /> information is true to-the-best' -of- my.-knowledge and belief. I WILL CALL FORA GROUT INSPECTION ! <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. By� Gc�,� `����� <br /> SIGNED HENNTNGS BROS, 1) LLING CO INC TITLE � t <br /> DRAW PLOT PLAN ON REVERSE STDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> DATE 121176. j <br /> ADDITIONAL COMMENTS: <br /> PHASE II-GROUT INSPECTION PHAS III AL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BYDATE / <br /> E H 1426 Rev. 1-74 - !�", 1./71� mw <br />