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y SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOh 0E"ICE - 1SE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> I Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 7- //S7� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued //-7-Z I <br /> (Complete In Triplicate) <br /> Application is nereby wade 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. R <br /> JOB ADDRESS/LOCATION. #! <br /> S.E_t_.�O�NER OF LONE 3'REERD MURPHY RDS"., CENSUS TRACT <br /> Owne'r's Name CHARLES 'ELSHOLZ: Phone ^ '° <br /> Address 16520 S.t MURPHY RD". .. City E,SCALON <br /> w <br /> Contractor's Name HENNINGS BROS. DRILLING -CO, ,INC. .License # 290813 Phone 545--1185 s <br /> 3525 FELADMALE AVE ., MDD.` "\ <br /> TYPE OF WORK "(Check) : NEW WELL _IXI DEEPEN /_/ RECONDITION /_/ DESTRUCTION /-J t <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /? <br /> DISTANCE TO NEAREST: SEPTIC TANK. ( EWER LINES T PIT PRIVY l <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT .., OTA £�L, <br /> PROPERTY- LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL I <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I Cable Tool Dia. of Well Excavati6n­ 26" <br /> Domestic/private ".!i Drilled Dia. of Well ,Casing 1 <br /> Domestic/public ! ,-Driven Gauge of Casing 4GA CJ` <br /> _ IrrigationXGravel Pack Depth of Graut Seal <br /> Cathodic Protection ..-,Rotary Type .of Grout <br /> Disposal -Other - Other Information SLAB-BY'-OWNER <br /> Geophysical a `, §urface Seal Installed By: _ <br /> F <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump .<H.P. <br /> PUMP REPLACEMENT: ' <br /> / / 'Stat Work Done <br /> PUMP ,REPAIR: / / State, Work Done; - r <br /> V_ <br /> DESTRUCTION 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 Bistrict <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 FINALIINSPECTION. <br /> SIGNED HENNINGn BROS. # aC1z`G TITLE SEC• ` <br /> (DRAW PLOT PLAN ON R RSE SIDE) <br /> FOR DEPARTMENT ISE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: 4' <br /> PHASE II GROUT 1149P EICT ION' -'"""''— -'PHASE TT /FIN - INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE � .. d <br /> _ /77 <br />__ E H 1426- Rev.. 1-74 .1- - <br />