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SAN JLOAQUI,N LOC: DISTRICT <br /> ~FOE OFFICE USE: 1601 E. Hazelton AVS'.. ockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application 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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> Smith <br /> JOB ADDRESS/LOCATION 2115 Albert Ct. & Hw,3 3 CENSUS TRACT <br /> Owner's Name Don Cose Phone 835-0966 <br /> Address P.O. BOX X26 City Tr;;e-3 <br /> Contractor's Name Hennings Bros. Drilling Co. Inc. License # 290813 Phone _52?_ .R, <br /> - - <br /> 2!T0_0 W. Rumble Rd., M�,Yd• <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION/ / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY N <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 11 " $ <br /> X Domestic/private Drilled Dia. of Well Casing " plastic <br /> Domestic/public Driven Gauge of Casing 160wall <br /> Irrigation Gravel Pack Depth of Grout Seal 501 <br /> Cathodic Protection X Rotary Type of Grout Bentonite `r <br /> Disposal Other Other Information Slab- by 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 /> 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 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 INSPECTIO <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED —Hennings Bros, Drill jpg Qop ,Ipp. bl, TITLE <br /> (DRAWPLOT PLAN ON REVERSE SIDE)' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE i <br /> ADDITIONAL COMMENTS: <br /> P I GRO T INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE�_7� INSPECTION BY DATE <br /> r— <br /> E H 1426 Rev. 1-74 'a 3/76 2M <br />