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e 1SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. //,/,0P <br /> Telephone: (209) 466-x6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 7 1;2 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issueddt <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/LOCATION S. Austin Rd.-1400' Ea st of Austini Rd . 9 CENSUS TRACT <br /> opposite Northland Ave. <br /> Owner's Name Wald.on Golien Phone 823-6722 <br /> Address 14304 S. Austin Rd . City Manteca <br /> Contractor's Name Hennings Bros. Drilling Co. Inc. License # 290813 Phone 522-1031 <br /> 2500 W. Rumble Rd. , o <br /> i <br /> TYPE OF WORK (Check): NEW WELL DEEPEN/ / RECONDITION / / DESTRUCTION /-T <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC TANK ICO_s SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER fGRit-X <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 1211 Q <br /> X Domestic/private Drilled Dia. of Well Casing a plastic <br /> Domestic/public Driven Gauge of Casing 160 wall <br /> Irrigation Gravel Pack Depth of Grout Seal 50r f\ <br /> Cathodic Protection X Rotary Type of Grout Bentonite <br /> Disposal Other Other Information Slab-by Owner <br /> Geophysical Surface Seal Installed By: driller <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materia a d Proc dure <br /> , <br /> c � 04a <br /> I hereby agre -to' comply with all laws and regulations 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 <br /> WELL DRILLERS REPORT of the well and notify them before putting thewellin use. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION 4 <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED HENNINGS BROS. DRILLING CO. INC. BY TITLE 221 ad,4 ,1 SEC. <br /> DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR JWPARTMENT USE ONLY 7 <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> �. <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE UI/FIN4 INSPECTION <br /> INSPECTION BY DATE 3-Zy---7 77 INSPECTION BY ZZ DATE 3 <br /> E H 1426 Rev. 1-74 a� .cf s -c� Yds ' � ?e�l�fF, f� Lr �.) /� 3/76 2M <br />