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_ J v SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton A'Ve. , Stockton, Calif. . <br /> f Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. Zi-10 314-) <br /> THIS PERMIT EXPIRES 1 YEAR FROM: DATE ISSUED Date Issued 2,22—,74 <br /> 2-76 <br /> (Complete In Triplicate) , <br /> Application <br /> riplicate)- <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. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 3708 Clark Drive CENSUS TRACT <br /> Owner's Name TUBBS ELECTRIC Phone 823-3814 <br /> Address 940 TRINITY City MANTECA 2 CAL. <br /> Contractor's Name HENNINGS BROS. DRILLING CO. INC-License # 290813 Phone 522-10314500 WEST RUDME F-D k <br /> i AL.. <br /> i <br /> TYPE OF WORK (Check) : NEW WELL /a DEEPEN / / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /7 x <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKSWNES PIT PRIVY <br /> SEWAGE DISPOSAL FI CESSPOOL/SEEPAGE PIT , OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cablejool Dia, of Well Excavation llr� <br /> X Domestic/private Drilled t �' <br /> /p Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing 12 Ga+ <br /> Irrigation Gravel Pack Depth of Grout Seal 5_ <br /> k <br /> Cathodic Protection - ' <br /> rotection „ XX Rotary itType of Grout Bentonite <br /> Disposal Other Other Information Slab by owner <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> S <br /> Type of Pump . i. z ....... ..t F5 H.P. <br /> PUMP REPLACEMENT: <br /> State Work�Done <br /> PUMP .REPAIR: /7 State Work Done k <br /> DESTRUCTION OF WELL: Well Diameter + '� Approximate Depth ' <br /> Describe MaterialandProcedure 1 <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 'constr'uction. Within FIFTEEN DAYS <br /> after completion of any work on anew 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 4. LL FOR A GROUT INSPECTIO <br /> PRIOR TO GROUTING AND A FINAL INSPECTION, <br /> SIGNEDTITLE -�-'f <br /> DRAW. PLT LAN 'ON RE FRSE SIDE) ; ;t <br /> l <br /> OR DEPARTMENT USE ONLY <br /> PHASE I of <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: ) <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY y. DATE - 7 -7.b INSPECTION BY DATE oP'- �6 <br /> E H 1426 Rev. 1--74 � 3/76 —i_ j <br />