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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS;QFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 11 AM Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76- /3/GJ <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 Joaguin Local Health District. <br /> 17250 So. Austin Rd. North of H 120 East side. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Tony Silva phone $23-5920 <br /> Address 17250 SO. AUSTIN RD. City -MANTECA <br /> Contractor's Name HENNINGS BROS. DRILLINGCOL INC. License <br /> # 290813 Phone 522-1031 <br /> 2500 West Ttumole Ra. MoZIesT0, ON_T <br /> 95350 <br /> TYPE OF WORK (Check): NEW WELL DEEPEN '/7 j <br /> RECONDITION /7 DESTRUCTION / <br /> PUMP INSTALLATION / / PUMP REPAIR I-7 PUMP REPLACEMENT /_'-f <br /> Other j� <br /> DISTANCE TO NEAREST: SEPTIC TANK UG/ 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 Cable Tool Dia. of We11 Excavation lls? <br /> X Domestic/private XDrilled Dia. of Well Casing -5 tt C <br /> Domestic/public Driven Gauge of Casing 12 Ga <br /> Irrigation Gravel Pack Depth of Grout Seal 50? <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: • Ll State Work Done <br /> PUMP ,REPAIR: /7 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> P P <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..weli. in.use.... The above <br /> information is true to the-beat of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED HENNINGS BROS. DRIELIN CO. , INC. TITLE B ZA__, BKPR <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I FORD ARTMENT USE ONLY <br /> APPLICATION' ACCEPTED BY DATE `ZL <br /> ADDITIONAL COMMENTS: <br /> PHASE 41 21W INSPECTION / PHASE III FINAL INSPECTION <br /> INSPECTION BY,G,J -ATE -.2 r 76 INSPECTION BY DATE <br /> air — <br /> E H 1426 Rev. 1-74 4/75 2M <br />