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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOSrflFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -?,K-/AjW <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> 4�o (Complete in Triplicate) 2o5-tro—OL <br /> Applicatifln-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. 1$b2a d th Rul s and Regulations of the San Joaquin Local Health District. <br /> North side o? <br /> JOB ADDRESS/LOCATION Lone 'free Rd. - East side of R. R. Tracks. <br /> CENSUs TRACT <br /> West of vaft *Ilea 4. <br /> Owner's Name John Vieira Phone 838-7+62 <br /> Address 22075 E. Lone Tree Rd. City Escalon, Cal. <br /> Contractor's Name Hennings Bros. Drilling Co. Inc. License 290813 Phone 52291031 y <br /> 2500 HUMFLE Ed._ ,_.' . 92150 <br /> e <br /> TYPE OF_WORK (Check): NEW WELL /V DEEPEN.-/-7. RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR j / PUMP REPLACEMENT /7 <br /> Other /J <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> 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 ll�r <br /> . XX Domestic/private Drilled Dia. of Well Casing <br /> r,t I Domestic/public ' Driven Gauge of Casing 1-2 Ca <br /> .- <br /> �' -.••Irrigation Gravel Pack Depth of Grout Seal 201 <br /> Cathodic ProtectionRotary <br /> - � Type of Grout Bentonite' <br /> Disposal q Other Other Information <br /> Geophysical Surface Seal. Installed By:- Driller <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT:-0 / IT State Work Done � = x <br /> PUMP '.REPAIR: y- /7 State Work Done <br /> ES:TRUCTIOW-OF WELL: Well Diameter f._, ' 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 /> RRIOR TO GROUTING AND A FINAL INSPECTION. 3 ' " % L <br /> SIGNED TITLE vN <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> POR DEPARTMENT USE ONLY.PHASE I <br /> / <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> .), 4 � ROUT INSPECT ON �� PHASE IIi FINAL, TNSPECTI N; <br /> INSPECTION BY "614'2e - DATE le > INSPECTION BY- , DATES - LAs <br /> �'I E H 1426 Rev. 1-74 <br /> I-7A I%A <br />