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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F09 OFFICE USE: 1601 E-, Hazelton Ave:. ,.Stockton, Calif. <br /> Telephone: (209), 466,-6781 <br /> APPLICATION'FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7341 <br /> THIS PERMIT EXPIRES 1 YEARFF'ROM,DATE ISSUED Date Issued 3 <br /> �. (Complete. In-Triplicate) <br /> Applicetion ,is hereby made to the Sett 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 /> Coutity Ordinance No. 1862 aiid the Rules and Regulations of the San Joaquin Local-Health District. <br /> 1 . <br /> JOB ADDRESS/LOCATION <br /> Mt. View off Corral Hollow at end of rd: ., CENSUS..TRACT <br /> - o <br /> Owner's Name Carl Hansen Phone 415--447-� 942 <br /> ' Address. 837. EasttStanley Blvd. A City :Liyermorey CAI. <br /> ' Contractor's Name HENNINGS BROS. CO. , INC:' License � 290.813 Phone 522-1031 <br /> 250U MT FLUIVWEE FLU... TTUPESTUTUAL953 50 _. <br /> TYPE OF WORK (Check): NEW WELL H DEEPEN '/_7 RECONDITION /7 DESTRUCTION f7 w— <br /> PUMP INSTALLATION ./ / PUMP REPAIR /� PUMP REPLACEMENT %T <br /> Other <br /> .DISTANCE TO NEAREST: SEPTIC TANK 0 SEWER LINES PIT PRIVY <br /> t }( SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> ./' PROPERTY LINE -- PRIVATE DOMESTIC WELL: DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL �,� CONSTRUCTION SPECIFICATIONS ll�t <br /> Industrial ► Cable Tool Dia:o£ Well' Excavation <br /> XX Domestic/private 1 Drilled Dia. of Well Casing- _ <br /> Domestic/public Driven Gauge of Casing, a <br /> Irrigation + . .Gravel Pack- Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout-. � entonite <br /> Disposal Other Other Information slauFy owner <br /> Geophysical Surface 'Seal Iiistalled 'By: driller .. <br /> PUMP INSTALLATION: ' Contractor <br /> 4 Type ,of Pump H.P. <br /> PUMP REPLACEMENT: / / IState Work Done <br /> PUMP '.REPAIR: - /-7 'State-Work'Done+ <br /> DESTRUCTION OF `WELL: Well Diameter Approximate Depth <br /> Describe katerial and Procedure . <br /> 'F Ihereby agree to comply with all Laws and regulations of the San Joaquin Local Health.Distriet <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 L my knowledge and belief. I WILL COKL 'FOR A GROUT INSPIKCTION, <br /> Ar <br /> PRIOR TO GROUTING"AND A FINAL INSPECTION. c�- <br /> SIGNED HENNINGS BROS. DRILLING TNG; TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE4& <br /> ADDITIONAL COMMENTS: <br /> PRASE If GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY 1A DATE <br /> 7 x' _ <br /> M -- <br /> :. ��a�_�` ae.,_ y_�4 r' is _�5 __2 <br />