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y I! <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFi('OFFICE USE: 1641 E. Hazelton Ave. , Stockton, Calif. .� <br /> Telephone: (209) 466-6781 ,-1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No2��G6J <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 /> 1 <br /> and/or install the,work herein described. This application is,made in compliance with San J6aquin , <br /> County Ordinance No.' 1862 aid the ,Rules. and Regulations of the.San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION J 13929,.,5 . Castle Rd. �..x., . CENSUS TRACT <br /> §. <br /> Owner's Name Rachel Silveira ' r � Phone 823--4060 <br /> Address _ _ J 1x929 1�S.- Castle Rd. City Manteca, -Cal S <br /> Contractor's Name Hennings Bros . Drilling Co. , Inc . License # 290813 phone 522-1031 <br /> 00 ivj '� Rumble Rd . Modesto Cal. 95350 <br /> i <br /> TYPE OF WORK (Check): NEW WELL AT DEEP' EN '/-7 RECONDITION /7 DESTRUCTION /_7 <br /> AL <br /> PUMPIIINSTLATION / / PUMP REPAIR /7 PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO .NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <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 1. Cable Tool Dia. of Well Excavation 11�t <br /> X Domestic/private I Drilled Dia. of Well Casing 2 <br /> Domestic/public i Driven Gauge of Casing ga <br /> Irrigation 4 Gravel Pack Depth of Grout Seal <br /> R Cathodic Protection �N'. X Rotary Type of Grout en on e �0 <br /> Disposal �. Other Other Information Slay _ y owner a <br /> Geophysical 'Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. �. <br /> PUMA REPLACEMENT: / / '-State Work Done <br /> P!M !REPAIR: /? ii+State Work Done <br /> ,DES RUCTION OF WELL: WelliIDiameter Approximate Depth <br /> Describe Material and Procedure <br /> p <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health- District <br /> and the State of California11,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 /> i information is true to the-best -of my knowledge and belief. I WILL CALL FOR A -GROUT INSPECTION <br /> 1 PRIOR TO OOUTING ANP A F NAL INSPECTIO . <br /> SIGNED--2 TITLE <br /> ij ( AW PLOT PLAN ON REVERSE SIDE . <br /> PHASE I� FOR I R <br /> DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ='I DATE - <br /> ADDITIONAL COMMENTS: !k <br /> PHASE ZZ GROUT„INSPECTION PHASE IZ FINAL INSPECTION <br /> INSPECTION BY 1DATE . =11=TAINSPECTION BY DATE <br /> E H 1426 Rev. 1-74 1-74 2M <br />