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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 PUNK? PERMIT Permit No. <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 Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> , JOB ADDRESS/LOCATION . �' CENSUS TRACT <br /> Owner's Name Casey Schneider Phone 835-5166 <br /> Address 23031 .Hansen Rd. City -Tracy.,,- Cal. <br /> Contractor's Name HENNINGS BROS . DRILLING' CO. , INC .;` License # -290813 Phone -522-1031 <br /> TYPE OF WORK (Check) : NEW WELD,_I7 <br /> DEEP. coNan0I�i7CTIQN�%T <br /> PUMP ISTALLATION %/ PUMP REPAIR /? PUMP REPLACEMENT /7 Q <br /> Other <br /> t DISTANCE TO NEAREST: SEPTIC TANK /,Qo SEWER LINES _ZC�7 • PIT PRIVY zw <br /> �X SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <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 11" <br /> XX Domestic/private Drilled Dia. of Well Casing 611 Plastic() <br /> Domestic/public Driven Gauge of Casing 70K <br /> Irrigation Gravel Pack Depth of Grout Seal 50 ? _ I <br /> Cathodic Protection f Rotary Type of Grout . ^Bentonite <br /> Disposal Other Other Information Slab by owner%.,- <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> i Typ6iof Pump H.P. <br /> PUMP REPLACEMENT: / /• State Work Done <br /> PUMP ,.REPAIR: / / State Work Done <br /> 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 CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINg INSPECTION. <br /> SIGNED : . ATLE <br /> ,E� W PLOT PLAN ON REVERSE SIDE <br /> R DE =T USE ONLY <br /> PHAS&,I <br /> APPLICATION ACCEPT DATE ' 7—?-7. <br /> ADDITIONAL COHMENTS . . <br /> ROUT: INSPECTWN - - AL YNSPBCTIO <br /> INSPECTION BY [aCA DATE Z `- INSPECTION BY rDATE �� 5 <br /> E H'1426 _ 1 /75 -2M_ <br /> Rev. 1-74 _ _._ <br />