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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF.��-FFICE USE: <br /> 1601 E. Hazelton Ave. , ,Stockton, Calif. t <br /> ' <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 i <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local. Health District. <br /> JOB ADDRESS/LOCATION 2 a <br /> �S CENSUS TRACT i <br /> Owner's Name Phone gab 11-0 _5> <br /> Address �Lk . <br /> . City <br /> Contractor's Name HENNINGS BROS. DRILLING CO. INC-p .License #290813 Phone 540--7185 <br /> 3525 i <br /> PELANDAU AVE. MODESTO " <br /> • i' <br /> TYPE OF WORK (Check) : NEW WELL /X/ DEEPEN / / RECONDITION /_/ DESTRUCTION F7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /7 i <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK tom_ SEWER LINES r PIT PRIVY <br /> X SEWAGE DISPOSAL� FIELD SS CESSPOOL/SEEPAGE PIT OTHER <br /> E <br /> PROPERTY LINPRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation { <br /> 11tt <br /> X Domestic/private Drilled Dia. of Well. Casing 6" last.i.e <br /> Domestic/public _Driven _ _ Gauge of Casing 160_ wall <br /> --•.— <br /> Irrigation Gravel Pack . Depth of Grout Seal 501 <br /> Cathodic Protection XRotary Type of Grout Bentonite <br /> Disposal, Other Other Information Slab—by owner <br /> Geophysical Surface Seal Installed By: driller <br /> PUMF INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP' REPLACEMENT: <br /> / / State Work Done <br /> PUMP ,.REPAIR: / / State Work Done <br /> DESJRUCTION 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 INSPECTION <br />'RIOR TO GROUTING AND A FINA I P CTI . TITLE r <br /> SIGNED, INC. <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY =� <br /> PHASE Ie, Q�(J <br /> APPLICATION ACCEPTED BY � DATE <br /> kDDITIONAL COMMENTS; CQ,1,1 - - - <br /> PHASE GROU ,INSPECTIONS PHAII/FlbTAL INS PECTIO , <br /> INSPECTION BY DATE _.. 3 INSPECTION BY DATE ZZI Z2;7 <br /> e !i'i3-rr W�fG+ <br /> tf772M <br /> E H 1426 Rev. 1-74 <br /> . .. " r <br />