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V SAN JOAQUIN LOCAL HEALTH- DISTRICT <br /> FOF, OFFICE USE: 1601 E. Hz.,elton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Zb a 4V <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued S�-7d <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct I <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 5101 Rd. on Old Hwy 50 at Curve CENSUS'TRACT <br /> Owner's Name DON COSE Phone 835-0966 <br /> Address P• 0. BOA; 326 City Tracy, Cal <br /> Contractor's Name Henninger Bros . Drilling Co. , Inc. License # 2908 Phone 522-1031 <br /> 2500 W. Rumble Rd Modes i <br /> TYPE OF .WORK (Check) : NEW WELL /X7 . DEEPEN / I <br /> PUO <br /> / /. DEST_RUCTION f� <br /> *� - <br /> -- --� - PUMP INSTALLATION PUMP REPAIR/ / PUMP REPLACEMENT /� <br /> Other <br /> TANCE TO NEAREST: SEPTIC TANK . SEWER LINES Z671 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 122 C, <br /> X Domestic/private Drilled Dia. of Well Casing 6T, <br /> Domestic/public Driven Gauge of Casing 160W P ag ti c <br /> Irrigation Gravel Pack Depth of Grout Seal 501 <br /> Cathodic Protection x Rotary Type of Grout Bentonite <br /> Disposal Other Other Information _ Slab bV owner. . <br /> Geophysical Surface Seal Installed By: driller" <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> R <br /> l DESTCT <br /> RUION OF W-ELL: 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 FI INSPECTION. <br /> SIGNED .o TIT <br /> ARAW P T PLAN 'ON RE RSE S11 ; <br /> I� FOR DEPARTMENT USE ONLY <br /> i PHASE I ;~ DATE 548.76 <br /> APPLICATION ACCEPTED BY ;L <br /> ADDITIONAL COMMENTS: <br /> PHA E II G OUT INSPECTIM PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE ---5 �� INSPECTION BY DATE <br /> f <br />� F H 1426 Rev_ 1-74 _ �6 2M <br />