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' " SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOHrOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209), 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. &-SS ) <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. .l 62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 2q2_1 5 �,' d STS <br /> JOB ADDRESS/.LOCATIONW1, of- Li=g 1 6002 E. of Kgster Rd. CENSUS TRACT <br /> Owner's Name Phone 5-41 <br /> AddressW—LinneCity Tracy <br /> Contractor's Name Hennings Bros. Drilling_Co.,,Inc. License # 29081 Phone 522-1031s <br /> 2500 W. Rumble Rd. Modesto { <br /> TYPE_OF....WORK (Check): NEW WELL IX DEEPEN- /7xN <br /> -RECONDITIO /_ DESTRUCTION � - - <br /> PUMP INSTALLATION / / PUMP REPAIR /-7 PUMP REPLACEMENT /-7 <br /> Other <br /> i <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANKf� SEWER LINES / PIT PRIVY <br /> X SEWAGE DISPOSAL FIELD CESSPOOL/s EPAGE PIT OTHER <br /> 0 i�PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL:ii <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation IP" <br /> $ Domestic/private Drilled Dia. of Well Casing <br /> t Domestic/publicDriven Gauge of Casing _ A- <br /> Irrigation Gravel Pack Depth of- Grout Seal 5al <br /> Cathodic-Protection $ Rotary Type of Grout B U33 t Qn ila- <br /> Disposal , Other Other Information <br /> S11h^h <br /> Geophysical Surface Seal Installed By:-.. _.,t3 ',i1 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done , <br /> PUMP'.REPAIR: / -7 State Work Done _ <br /> PES•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 i:g' true to the-best of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNEDBennings 0IncITITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE . <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED/13Y . 120 DATE <br /> ADDITIONAL CO <br /> P S .I UT INSPECTION P E UINAL INSPECTION <br /> INSPECTION DATE INSPECT DATE -/ <br /> E H 1426 Rev. 1 .74 1..71a 7M <br />