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'' SAN JOAQUIN LOCAL HEALTH DISTRICT F <br /> FOR''GFFICE .USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 2,1102 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> r (Complete In Triplicate) <br /> Application is hereby made toilthe 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 an41the Rules and taulations of the San Joaquin Local Health District. <br /> 1 <br /> JOE ADDRESS/LOCATION f ! 7// Cp CENSUS TRACT <br /> Owner's Name .{ Phone — (+7. <br /> Address Q City • <br /> Contractor's Name HENNINGS !BROS. DRILLING COINC. License #116322 Phone 522-5643 <br /> 2500 W. <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN /? RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> F <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGEibISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _ Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing �y <br /> Domestic/public i Driven Gauge of Casing <br /> Irrigation j Gravel Pack Depth of Grout Seal <br /> Other I1 Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type cf Pump H.P. <br /> _ E� <br /> PUMP REPLACEMENT: /7 State Work Done <br /> PUMP REPAIR: / / State Work-Done <br /> ESTRUCTION 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 /> i 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. <br /> HENNINGS BR055 DRILLING CO.9N BOOKKEEPER <br /> SIGNED . TITLE <br /> i (DRA PLO -PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE -" <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY 9 DATE INSPECTION BY DATE IV-19- <br /> CALL <br /> / - <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 7/72 1M C <br /> E H 14'26 <br />