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( SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORS OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. _ <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR-WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S- S UZ/ r <br /> THIS PERMIT EXPIRES .1 YEAR FROM .DATE ,.,ISSUED Date Issued �5 <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 Regulations of the San -Joaquin Local Health District. <br /> F <br /> JOB ADDRESS/LOCATION 3ad.. Z2f CENSUS TRACT <br /> Owner's Name CASEY =MR. SCHNEIDER, BLDR <br /> -&�rr Phone , 835-0444 <br /> Address- 23034.,SOUTH HANSEN RD.. _ <br /> City TRACY, CAL. <br /> HENNINGS BROS . DRILLING CO. , INC.. License !� ' 290$13Phoae 52z-1031 } <br /> Contractor's Name I <br /> West u � . <br /> -__952 <br /> 5OY - <br /> TYPE OF WORK (Check) : NEW WELL. XV DEEPEN '/7 RECONDITION '17 DESTRUCTION /_7 <br /> PUMP. INSTALLATION / J PUMP REPAIR /7 PUMP REPLACEMENT- 1-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY j <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAG -PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL'� PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial „l Cable 'Tool Dia. of Well Excavation <br /> XX Domestic/private - Drilled Dia. of Well Casing 5 7T <br /> Domestic/public + Driven Gauge of Casingas L7150 <br /> Irrigation � - Gravel Pack Depth of Grout Seal 5Q , } <br /> Cathodic Protection - Rotary Type of Grout en onx ,e <br /> Disposal I Other Other Information ' Slab by owner ! <br /> Geophysical Surface Seal Installed By: <br /> driller <br /> PULP INSTALLATION: . Contractor <br /> K - Type. .of Pump H.P. <br /> PUMP REPLACEMENT , State Work Done <br /> L_/ <br /> - ...,. <br /> -PUMP REPAIR-:-- -sState Work Done'' <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to complylwith 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. i.n.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. � <br /> SIGNE HffJ NINGS BROS. D ILLING INC. TITL Y ,(� 2 <br /> DRAW PLOT PLAN ON REVERSE SIDE : <br /> 1, eDE NT USE ONLY . <br /> PHASE I <br /> APPLICATION ACCEPTED DATE <br /> ADDITIONAL COMMENTS: J. <br /> PHASE II GROUT INSPECTION' . <br /> NSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE / <br /> . t i <br /> E H 1426 Rev. 1-74 1 =/7 E� 9M. <br />