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A SAN JOAQUItt^^LOgR,, HEALTH DISTRICT <br /> E'OE.OVVTCE USE: ' 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> Y/ %, Telephone: (209) 466•-6781 <br /> 'APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,? ,7-]& <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7 <br /> .(Complete In Triplicate) ' <br /> Application is Aereby 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 1501 HOLLENBECK ROAD— OFF FARMINMON RD CENSUS TRACT <br /> Owner's Name DOUGLAS ALLEN Phone 931--0247", a. <br /> Address 1. 320-HUBEARD AVE., City STOCKTON s - CAL. � <br /> HENNINGS BROS. DRILLING INC. 290$13 525-11$5 r <br /> Contractor.,.s..Name CO. , _.License .4� Phone----. <br /> _ 3 2 i , -=. <br /> TYPE OF WORK (Check) : NEW WELL'`/ )f_'DEEPEN /_7RECONDITION /7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Otlre / •/ <br /> DIrTCE TO NEAREST: SEPTIC TANK >Sy SEWER LINES ..PIT PRIVY <br /> SEWAGE DISPOSAL FIELD,>/d0 <br /> CESSPOOL/SEEPAGE PIT /SO OTHER <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 11,f <br /> X 'Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of ,Casing 160 Wall <br /> Irrigation Gravel Pack Depth of Grout Seal 501 <br /> Cathodic Protect_ ion Rotary Type of Grout Bettonite <br /> Disposal Other Other Inftormation Slab Ty oWne,r <br /> Geophysical � Y Surface Seal, ins talled By: <br /> PUMP .INSTALLATION: Contractor ' -S. Y m, <br /> 4 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done ` <br /> PUMP�REPAIR Lw ,:— - —/,T� ;,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 FIFL'EEN 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 ot�fy 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 TOG 0[JTING ANDA RNAL INSPECTIOJN. <br /> S GED TITLE <br /> D PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> jo- <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL: INSPECTION <br /> INSPECTION BY DATE _9- ?7 INSPECTION BY DATE 7-�9. 7 <br /> E H 1426 Reu 1-74 117T . 2M <br />