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SAN JOAQUYN 1 C L HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton Calif. <br /> Telephone: . (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. i -1ogW <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3a n r <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. 1662 end the Rules and Regulations of the 'San -Joaquin Local Health.District. <br /> JOB ADDRESS/LOCATION= qw CENSUS TRACT 4 <br /> Owner's Name Delmar Auch P608.211-3-$35_2593 <br /> Address .1369 Lincoln Blvd City Tracy- Cal. ` <br /> Contractor's Name _ _Hennings Bros. Drillink Co_ _Inc'.• License # 290813 Phone 522-1031 <br /> Ed. . <br /> TYPE OF WORK (Check): NEW WELL '/U DEEPEN /7 RECONDITION /7 DESTRUCTION ./-7 <br /> PUMP INSTALLATION/� PUMP REPAIR J PUMP REPLACEMENT /7 <br /> Other /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY Nt , <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT 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" <br /> X Domestic/private Drilled Dia. of Well Casing a <br /> Domestic/public Driven Gauge of Casing 160 w <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> r <br /> Cathodic Protection X Rotary Type of Grout gana1tQ ...�_ <br /> Disposal Other . Other Information <br /> GeophysicalSurface Seal Installed By:, 'driller <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump S.P. <br /> PUMP REPLACEMENT: /_/ State Work Done <br /> PUMP ,.REPAIR: <br /> /� State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> Y 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, T will furnish the San Joaquin Local Health District <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 INSPECTION <br /> PRIOR TO GROUTING 'AND A FINAL INSPECTION. <br /> SIGNED HENNTNGS BRO . DRILLING CO. INC . Tl�� -�-� ad,0;1,j B12r <br /> {DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE I3' GROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY DAT$ 3—�7_ INSPECTION BYE DATE <br /> M <br /> E.H. 142h sari_ I_7A 1.J7e ops �. <br />