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V SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF `OFFLCE USE: 160 . He-elton Ave. , Stockton, Cal <br /> Telephone: (209) 466-6781 u <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 26 -3 a �IrJ <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 5101 Rd. on Old Hwy 50 at Curve CENSUS TRACT <br /> Owner's Name DON COSE Phone $35-0966 <br /> Address P. 0. BOX 326 City Tracy, Cal <br /> Contractor's Name Hennings Bros . Drilling Co. , Inc. License U 290813 Phone 522-1031 <br /> 2500 W. Rumble Rd b2odestc Calif- <br /> TYPE <br /> alif TYPE OF WORK (Check) : NEW WELL E/- DEEPEN / / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other <br /> TANCE TO NEAREST: SEPTIC TANK 657 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL — PUBLIC DOMESTIC WELL — Cn <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS l <br /> Industrial Cable Tool Dia. of Well Excavation 12" <br /> X Domestic/private Drilled Dia. of Well Casing 61i <br /> Domestic/public Driven Gauge of Casing 160W Plastic <br /> Irrigation Gravel Pack Depth of Grout Seal 501 <br /> Cathodic Protection X Rotary Type of Grout Bentonite <br /> Disposal Other Other Information Slab by owner , <br /> Geophysical Surface Seal Installed By: driller' <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FID INSPECTION. I <br /> SIGNED f. TIT / <br /> DRAW PTOT PLAN ONREVERSE SI E) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 5.2$ 7Ei <br /> ADDITIONAL COMMENTS: .e.. p �pp_ n <br /> PHA E II,GOUT INS13ECTIM PHASE III/FINAL INSPECTION <br /> INSPECTION BY /i DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 <br /> 3/76 2M <br />