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V) JOAQUIN LOCAL HEALTH DISTRICO ✓ , <br /> FOR,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <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 ,tJ-/S 76 <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 Joaqul <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION HARLEN RD.-EAST OF FREEWAY8APROX. 28001 - CENSUS TRACT <br /> EAST OF HARLEN 14001 NORTH OF SQUIRES RD. ,NEAR gP TRACK <br /> Owner's Name MIDDLE K FARMS CURIIS LEWIS Phone 9 2-1 1 <br /> Address 12644 S. HARLEN RD. City '- LATHROP <br /> Contractor's Name HENNINGS BROS . DRILLING CO. IINC. License # 290813 Phone 522-1031 <br /> 9500 W. RUMBLE RD. . MOD. <br /> TYPE OF WORK (Check) : NEW WELL /X7 DEEPEN/7 RECONDITION /7 DESTRUCTION / <br /> PUMP INSTALLATION/—/ PUMP REPAIR/% PUMP REPLACEMENT /7 <br /> Other r_/ I — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER C�/J <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 pptl <br /> Domestic/private Drilled Dia. of Well Casing 1411 � <br /> Domestic/public Driven Gauge of Casing q./ h G.4 s <br /> X Irrigation X Gravel Pack Depth of Grout Seal <br /> Cathodic Protection X Rotary Type of Grout <br /> Disposal Other Other Information Sla,h- by oum Pr \ <br /> Geophysical Surface Seal Installed By: 4 <br /> PUMP INSTALLATION: Contractor `( <br /> Type of Pump H.P. d <br /> PUMP REPLACEMENT: / / State Work Done l <br /> _ P <br /> PUMP, .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> a <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 t <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. <br /> SIGNED HFNNTNGS RROS . DRILLING CO.e INC . BY TITLE 4adjl As � . /,Z SEC <br /> (DRAW PLOT PLAN ON REVERSE SIDE)�_ — <br /> E <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 1'/7 7� <br /> APPLICATION ACCEPTED BY DATE 7 / <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE FIN INSPECTION <br /> INSPECTION BY DATE INSP,RCTION BY TE <br />