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ay✓ 1N JOAQUIN LOCAL HEALTH DISTRI( <br /> FOR.OFFICE USE: 16CI E. Hazelton Ave. , Stockton, Cal-If. <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 <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Stow Road CENSUS TRACT <br /> Owner's Name Mrs . Nunoz 1�-- Phone 463-0212 <br /> Address 1567 Newport Rd. City Stockton,Cal <br /> Contractor's Name Hennings Bros . Drilling Company, InEtcense # 290813 Phone 522-1031 <br /> 2500 West Rumble Rd. Modesto, Cal. <br /> TYPE OF WORK (Check) : NEW WELL A7 DEEPEN /_-7 RECONDITION /_- DESTRUCTION /-7 <br /> AL <br /> PUMP INSTALLATION /—/ —PUMP PUMP REPAIR /—/—PUMP PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OPOR <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 20TT <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 3/16 <br /> X Irrigation -�- Gravel Pack Depth of Grout Seal <br /> Cathodic Protection —� Rotary Type of Grout <br /> Disposal Other Other Information Slab by owner <br /> Geophysical Surface Seal Installed By: ZCX c ]ffx <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: j—/ State Work Done <br /> PUMP .REPAIR: /7 State Work Done <br /> 2ES•TRUCTION 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 L FOR A GROUT INSPE ION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. y <br /> SIGNED g_e_nninEs Bros , Dril ling Co. , Inc. TITLE L�E� <br /> (DRAW PLOT PLAN ON REVERSE SIDE bkpr <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY /p DATE fl-FZZ <br /> ADDITIONAL COMMENTS: <br /> PHASE II. GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ZI - <br /> E H 1426 Rev. 1-74 ^" <br />