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Vj JOAQUIN LOCAL HEALTH DISTRIC S <br /> FOR OFFICE USE: ,. 16 . Hazelton Ave. , Stockton, Ca <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. o Sw <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 Joaquii <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 FREEWAY.APROX 28001 CENSUS TRACT <br /> EAST OF HARLEN 14001 NORTH OF SQUIRES RD. ,NEAR P TCK <br /> Owner's Name MIDDLE K FARMS CURftS LEWIS Phone 9 2-1RA1 <br /> Address 12644 S. HARLEN RD. City LATHROP <br /> Contractor's Name HENNINGS BROS . DRILLIDiG CO. ,INC . License d 290813 Phone 522-1031 <br /> 2500 W. 1aMLE RD. . MOD. <br /> TYPE OF WORK (Check) : NEW WELL /%-7 DEEPEN/_7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR/% PUMP REPLACEMENT /7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY �st <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER �+g <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 2;)rr <br /> Domestic/private Drilled Dia, of Well Casing 1411 <br /> Domestic/public Driven Gauge of Casing16 CA <br /> X Irrigation X Gravel Pack Depth of Grout Seal f <br /> Cathodic Protection X Rotary Type of Grout <br /> Disposal Other Other Information Slah- by nwnPr <br /> Geophysical Surface Seal Installed By: <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 FINAL INSPECTION. <br /> SIGNED HENNTNGS BROS . DRILLING CO INC BY TITLES SEC . <br /> iY1CIlfP�L ? _ oL�CZ{./ <br /> (DRAW PLOT PLAN ON REVERSE SIDET— <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE �f <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE FIN INSPECTION <br /> INSPECTION BY DATE INS/P,R //� A <br /> CTIONBY r / TE <br />