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" . SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> EFrrOFF10E USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 3 <br /> I <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �OS'CrJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /-/¢-7� <br /> (Complete In Triplicate) """�""" J <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct J <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 Re ulations of the San Joaquin Local Health District. <br /> I <br /> JOB ADDRESS/LOCATION /y ��i �� CENSUS TRACT <br /> •i <br /> Owner's Name Phone 0 <br /> E <br /> Address : ��9 ��7� � '` �`_� - Cit <br /> y l <br /> Contractor's Name HENNINGS BR=* DRILLING CO.i INC ...License # 290813 Phone 522--10371- <br /> Zt),Uu W. ITUEMILEP 1W.- TV10IMSTIVI CA-DO 95350 <br /> ... <br /> TYPE OF WORK (Check): NEW WELL ,f DEEPEN.-/-7 RECONDITION /_ - DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR ./7 PUMP REPLACEMENT 17 <br /> Other Y7 — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD r . 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 W <br /> Domestic/private '4' L7?rilled Dia. of Well, Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal �g <br /> Cathodic Pres <br /> otection F -Rotary Type of Grout _ <br /> Disposal M i Other Other Information- <br /> -Geophysical.. <br /> nformation-Geophysical r <br /> Surface.-Seal- Ins,t,alled By: <br /> PUMP INSTALLATION; Contractor <br /> Type of Pump H.P. 4 <br /> PUMP REPLACEMENT: /—/- State Work Done -� <br /> Fr ! <br /> PUMP `.REPAIR: /? Sate Work Done <br /> ES;TRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure 4 <br /> ,r <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 regulat.irig well construction. Within FIFTEEN DAYS <br /> after completion of my work ori 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 FORA GROUT INSPECTION <br /> PRIOR. •TO GROUTI AND A F NAL INSPECTION. ; <br /> SIGNEDi TITLE : , <br /> �. DRAW PLOT PLAN ON REVERSE SIDE <br /> 'FOR DEPARTMENT USE ONLY <br /> PHASE I /'� <br /> APPLICATION ACCEPTED"By .. DATE <br /> ADDITIONAL COMMENTS: i <br /> PHASE II GROUT INSPECTION PHASE I FINAL INSPECTION <br /> INSPECTION BY. • DATE, /,- �p. INSPECTION BY DATE <br /> ! a <br /> 1� 1E H 1426 Rev. 1-74 1-74 2M <br />