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' SAN JOAQUIN LOCAL_ HEALTH.DISTRICT''"` <br /> 'Y FOF _OOICE USE: ud '1601_ E. Hazelton Ave. , Stockton, Calif. <br /> Telephone': (209) 466-6781 a <br /> APPLICATION ,FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, s3&) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -77 <br /> (Complete In Triplicate) r <br /> Application is Aereby made to the San Joaquin Local Health District for a permit tq construct <br /> and/or install the work herein degcribed. 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 0 HWy CENSUS TRACT <br /> FRONTAGE RD. � NORTH SIDE <br /> Owner's Name RALPH R. SMITH Phone - 823--576.8 <br /> Address 5175 E. BRUNSWICK RDs City MANTECA ' <br /> Contractor's Name HENNINGS BROS. DRILLING CO.INC'a License # - -290813.Phone -545--1185 1 <br /> -.3525 PELANDALE AVE . , MOD". <br /> . a <br /> TYPE OF WORK (Check); NEW WELL /X-7 DEEPEN /� RECONDITION /-7 DESTRUCTION f7' <br /> PUMP INSTALLATION j_/ PUMP REPAIR / / PUMP REPLACEMT <br /> Other - -- <br /> DISTANCE TO NEAREST: SEPTIC TANK __/00p SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER WE-U--50 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC LL � <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS.- <br /> ,Indus tr;La <br /> PECIFICATIONS.,Industrial Cable Tool Dia. of Well Excavation " 1211 U� <br /> X r Domestic/private Drilled Dia. of Well Casing 8"s LASTI l <br /> Domestic/public Driven Gauge of Casing _`— 160ALL <br /> Irrigation Gravel Pack - Depth of Grout Seal <br /> Cathodic Protection X Rotary 1,Type of, Grout`r'2 BENTONITZ ` <br /> Disposal Other Other Information <br /> _SJAB,:Bj. OWNER <br /> Geophysical Surface Seal -Installed By: DRILLER <br /> PUMP INSTALLATION: Contractor - <br /> Type of Pump H.P. - <br /> E PUMP REPLAC iT: / / State Work Done <br /> I PUMP :REPAIR; t�I � <br /> `) -State Work pone <br /> STR[JCTION OF11 Diameter iy/C Approximate Depth U///C . <br /> Describe Material and Procedure <br /> 4 Zz. , <br /> I hereby agree' to comply with all laws and regulatioVis of the San Joaquin L cal HeItIth bistri.ct <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. I WILL CALL FOR A GROUT INSPECTION. <br /> PRIOR TO GROUTING *AND A.FINAL INSPECTION. <br /> SIGNED HENNINGS BROS. . j INC. BY TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL"COMMENTS: <br /> PiMSE F G UT INSPECT12 PHASE I I INAL NSPECTION <br /> INSPECTION BY DATE INSPECTION BY , TE <br /> E H`1426 Rev:' 1-74 j 1177: _ 2W.., <br /> t x:.1.11 we/� � <br />