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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0VOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. r(\o-'CSS Uw <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 /> JOB ADDRESS/LOCATION_ /A. ¢ 2 S 5 IV4&2rh C- i` ,CENSUS TRACT. <br /> DELMAR AUCH j <br /> Owners Name L�G/ - Phone 83 5 2 593 <br /> Address 1369 LINCOLN BLVD. TRACY CAL. <br /> City <br /> Contractor's Name Hennings Bros. Drilling Co. , Ind .' License # 29.0813 Phone 52.2-.1031 <br /> 2500 W. Rumble Rd. Modesto Cala 95350 <br />-TYPE OF WORK (Check): NEW WELL. ,g DEEPEN '/_7 RECONDITION I7 DESTRUCTION 17 A <br /> PUMP INSTALLATION/ / PUMP REPAIR'/ / PUMP REPLACEMENT /7 i <br /> Other <br /> .DISTANCE TO NEAREST: SEPTIC TANK fD D SEWER LINES 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 11'� <br /> X Domestic/private Drilled Dia, of Well Casing bit <br /> Domestic/public Driven Gauge of Casing Pl-astic <br /> Irrigation Gravel Pack Depth of Grout Seal 0 <br /> Cathodic Protection X - Rotary Type of Grout 'Bentonite <br /> __Disposal Other Other Information� Sla vwner <br /> ,-Geophysical Surface Seal Installed 'B : driller <br /> :PUMP INSTALLATION: Contractor <br /> Type .of Pump H.P. <br /> :PUMP REPLACEMENT: State Work Done Y <br /> ,'PUMP .REPAIR: / / State Work Done i <br /> .DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure - <br />'E I hereby agree to comply with all. laws and regulations of the San Joaquin Local Health District <br /> t -atd 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 FINAL INSPECTION. Bk• <br /> SIGNED .Rennin s Bros. r 1fig • , Inc. TLE CIA, <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I / _ <br /> APPLICATION' ACCEPTED BY <br /> E ADDITIONAL COMMMS: } <br /> PHASE II GROUT INSPECTION PHASE II FINAL INSPECTION , <br /> INSPECTION BY DATE 3 7--Ii INSPECTION BYDATE -/ y7 blAz <br /> + <br /> R R 1LIA De.. 7_7/. 1 /7� 7M <br />