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JIM ; f <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,; U <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued _:, 2-,3 <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 Ru es and Regulatio s of the San Joaquin Local Health District. G <br /> JOB ADDRE55Koste+ Rd IvTorth of Schoa CENSUS TRACT <br /> iOwnerts Naive John Reece _ Phone 8 <br /> Address 28291 South Chrisman •Rd. City Tracy <br /> Contractor's Name Hennings Bros. Drilling Co InC. License t16322 W Ptione���..�h1�q <br />-TYPE-OF`"WOR[C ('Check): `I Ew 'WELL /x/ DEEPEN / 7F RECONDITION /7 DESTRUCTION /_7 i <br /> r - PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT V-7 <br /> Other <br /> -- <br /> DISTANCE TO NEARES : SEPTIC TANK � SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD <br /> CESSPOOL/SEEPAGE PIT OTHER � I <br /> v �INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Sty <br /> Industrial Cable Tool Dia, of Well Excavation j 311 <br /> _ V' <br /> y Domestic/private _ Drilled Dia, of Well Casing xir t <br /> Domestic/public Driven Gauge of Casing 2 Qa <br /> Irrigation Gravel Pack Depth of Grout Seal 5Q1 <br /> -,Other -, Rotary Type_of Grout Rentnni tom. _ <br /> Other Other Information .5/# -- R DSS lVe:: ' <br /> • <br /> PUMP INSTALLATION: Contractor <br /> IG <br /> i 'Type of Pump H.P. <br /> e. <br /> PPUMP REPLACEMENT: 5 / / State Mork Done I' <br /> :P kiEPAIR: ' / / State Work Done <br />. DESTRUCTION OFJWELL: Well Diameter i Approximate Depth <br /> Describe Material and Procedure <br /> I r - <br /> I hereby agree tacomply with all laws and regulations of the San Joaquin Local Health District <br /> . i .... <br /> and the Statell pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> ,5 <br /> after comp letion.,of��y�work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS RERORT, nfthe well and notify them,before.putting the well in use.;' The above <br /> `; <br /> informatio is truer 6. the b st oflmy knowledge and belief. <br /> n _ <br /> SIGNED s TITLE <br /> PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br />�PHASE I kin <br /> ',APPLICATION ACCEPTED BY DATE <br /> ``A &LTIQNAL COMMEN,T31111, <br /> ,� • ' <br /> (( P II U' &INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTIOiDA'le-Ezp _� ^ y ',.INSPECTION BY DATE <br /> ' CAL <br /> L'FOR A GROUT INSPECTIONS k1OR TO G UTING AND FINAL INSPECTi <br /> El1426 7/72 1M <br /> . ., <br />