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-a(v6t7 S14VIS 5a384�13 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO 70FFICE USE: 1601 E. Hazelton Ave. , Stockton, .Calif. <br /> Telephone: (209) 466-6781 ' <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S-S`d a 4J <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 Regu].at# c g fan Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 30,000 Kasson Road _ ✓��n7f` ��Z��/�Yv77 CENSUS TRACT �- <br /> Owner's Name San Joaquin River Club Phone 835 -1969 <br /> Address 30,000 Kasson Rd. Box 150 City Tracy, Calif. <br /> Contractor's Name <br /> Hennings Bros . Drilling Co. , Inc . , • �e 90813 522-1031 <br /> . Phone <br /> TYPE OF WORK (Check): NEW WELL /7 DEEPEN /7 RECONDITION /7 DESTRUCTION /1 <br /> PUMP INSTALLATION/ / PUMP REPAIR/_7 PUMP REPLACEMENT F7 <br /> Other /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK 130 SEWER LINES 0 PIT PRIVY 0 ' <br /> 1C SEWAGE DISPOSAL FIELD 105 CESSPOOL/SEEPAGE PIT 0 OTHER 0 <br /> PROPERTY LINE 27 PRIVATE DOMESTIC WELL'..Q.._ PUBLIC DOMESTIC WEI,L <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 1111 <br /> _- Domestic/private �- Drilled Dia. of Well Casing <br /> X Domestic/public Driven Gauge of Casing MEEN' � <br /> Irrigation Gravel Pack Depth of Grout Seal 5() T <br /> Cathodic Protection —X Rotary Type of Grout Bentonite <br /> Disposal Other Other Information Slab by owner <br /> Geophysical Surface Seal Installed Bre rl e r <br /> O <br />,PUMP INSTALLATION: Contractor %- C/v d sY.»��,-r• <br /> Type of Pump v s,. H.P. / <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: /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 them before putting the,-well in use.. The above <br /> information is true to the—best—of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. BY <br /> SIGNED HENN INC . TITL .e E' BKPR`SECT 1 <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR W2ARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 7 <br /> E H 1426 Rev. 1-74 <br />