Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR70FFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> I APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '22-161) <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 Joaquin: <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATI.ON 1 600 SOUTH COTTAGE . MANTECA CENSUS TRACT <br /> SUMMER HOMES T <br /> Owner's Name RON SAMPLE Phone <br /> Address 324 STAFFORD WYY t City MANTECA <br /> Contractor's Name HENNINGS BROS. DRILLING CO. - INC. License #116322 Phone 522-5643 <br /> 'TYPE OF WORK (Check) : NEW WELL /X_7 DEEPEN RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other -- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br />` SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELT. <br /> CONSTRUCTION SPECIFICATIONS <br /> _ Industrial Cable Tool Dia, of Well Excavation I Ott Qj <br /> Domestic/private --- Drilled Dia. of Well Casing 61 <br /> Domestic/public Driven Gauge of Casing 12 GA <br /> Irrigation Gravel Pack Depth of Grout Seal s, <br /> Other Rotary Type of Grout <br /> Other Other Information <br /> t <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done s <br /> PUMP" REPAIR: / / State Work Done Y + <br /> .RESTRUCTION 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. <br /> HENNI GS BROS. DRILLING CO. , INC. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY / DATE INSPECTION BY / DATE 0-� <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M �. ' <br />