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i ;OFFICE USE• SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. ; Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> t <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7-r- <br /> � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date Issued r <br /> A (Complete in Triplicate) , <br /> pplication 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 /> JOB ADDRESS/LOCATION 28932 S Lehman Rd. 1/8 Miles South of Linne Rd <br /> CENSUS fiACT S '� <br /> Owner's Name •AnthonM Souza ( Franklyn Cole, Bldg Cont) $35-071$ . <br /> Phone <br /> f Address 28932 S., Lehman Rd. <br /> City , Tracy, Calif. <br /> r Contractor's Name Hennin s 'Bros . Drilling Co. , Inc: L 2.9Q$13 . 522--1031 <br /> 25 um e o e �� - Phone <br /> TYPE OF WORK (Check): NEW WELL U7 DEEPEN '/? RECONDITION /-` DESTRUCTION /7 <br /> PUMP. INSTALLATION / PUMP REPAIR/7 PUMP REPLACEMENT 1-7 Q} <br /> Other / ! <br /> Ob <br /> DISTANCE TO NEAREST: SEPTIC TANK 12017 SEWER LINES PIT PRIVY � r <br /> SEWAGE DISPOSAL FIELD _ CESSPOOL/SEEPAGE PIT '? '' OTHER-, , <br /> + OTHERS ., <br /> PROPERTY LINE •- PRIVATE DOMESTIC WELL" PUBLIC`1�501MEsii6 WELL <br /> INTENDEDUSE TYPE OF'WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 4 Cable Tool Dia. of Well Excavation <br /> _ XX_ Domestic/private Drilled Dia. of Well Casing- s f }x+ v 4 <br /> Domestic/public Driven Gauge of-Casing, ;, <br /> Irrigation + Gravel Pack- Depth of Grout Seal---j w 77 <br /> 12 a <br /> Cathodic Protection Rotary _ Type of Grout Bentonjt6 <br /> Disposal <br /> Other . Other Information ' ' a y owner <br /> Geophysical. — -�_ Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor � <br /> Type of Pump <br /> H:P. <br /> PUMP REPLACEMENT: / / State Work Done _7[ <br /> PUMP ,REPAIR. <br /> . . .. �,.�._. ; —S to te•-Work=Done=-• <br /> DESTRUCTION OF WELL: ,-Well. Diameter <br /> Describe Material and Procedure Approximate Depth <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. <br /> 5IGNED <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> F DEP T NT USE ONLY <br /> AI'PLxCATIQN ACC ED BY � <br /> ADDITIONAL COMMENTS:PHftU DATE 75' <br /> GROUT 1NSPECT9N P I INAL INSPECTION <br /> INSPECTION BY I E —2 l INSPECT ' <br /> E H 1426 Rev. 1-74 ,_ <br />