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f i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE .USE 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> r ( W lJ2c�c. aE <br /> Telephone : _(209)- 466-6781 f <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. U:�al,) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) .^ 3 <br />,-Application is hereby made to the San Joaquin Local Health District for a permit o construct' <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinanc No.- 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> p <br /> .TOB ADDRESS/LOCATIONSTT)p CENSUS TRACT II <br /> Owner's Name BILL SAENGERPhone 52 _1 - <br /> Address 301 STANDIFORD AVE. AFT, 144 city - MODESP O1 <br /> Contractor's Name BENNINGS BROS. DRILLING GO -.License # p4� Phone E�W; � � 2 ri-- <br /> 3525 PELANDALE AVE. MOD. <br /> I .,,. <br /> TYPE OF WORK (Check) : NEW WELL /X/ DEEPEN /_/ RECONDITION /_/ DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK / SEWER LINES PIT PRIVY ,� h <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT ,OTHERl�ELL-�p <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC. WELL ' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> S I .� <br /> In Cable Tool Dia, of Well Excavation _ 262 <br /> Domestic/private Drilled_ Dia. of Well Casing 1;8se; 0 <br /> Domestic/pubilic Driven Gauge of Casing --- 4GA <br /> X Irrigation � Gravel Pack Depth of Grout Seal <br /> Cathodic•-,P.rotection , Rotary Type of Grout <br /> Disposal J Other Other Information SLAB-BY OWNER ' k <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: j�=tilr <br /> ' <br /> Contractor <br /> Type of Pump .,.,._...._ H.P. <br /> PUMP REPLACEMENT: / / State Work Done �I <br /> PUMP`.REPAIR: --State Work Done . <br /> DESTRUCTION OF WELL: Well Diameter 3 Approximate Depth �I , <br /> Describe Material and Procedure , F <br /> I hereby agree .to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaiTir _toor regulating well "construction. Within FIFTEEN DAYS <br /> after completion of my work on a new�.we_11, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well-.and; 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. <br /> SIGNEDHENNTHaa_B110q -RV' <br /> TITLE <br /> i DRAW PLOT PLAN REVERSE SIDE) 1• t <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - /L`" <br /> APPLICATION ACCEPTED BY DATE 1D-I`x,--77 <br /> ADDITIONAL COMMENTS: iR <br /> PHASE II GROUT INSPECTION PHASE lj, /FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY y DATE &,,'2211 <br /> -E H 1426 MaU_ 1-76 <br />