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r' <br /> SANJOAQUiN .00AT HEALTH DISTRICT <br /> EOF.-OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ' Telephone: (209) 4666781 <br /> i t APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT- EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7� X73 <br /> 4 (Complete- In Triplicate) <br /> Application is hereby made.1to 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 Joaquii <br /> County Ordinance No. 1862 'and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONX _7 s ���� I� CENSUS TRACT <br /> Owner`s Name ROBERT G OODWIN Phone 823-6748 <br /> Address 12043 EAST HWY 120 City MANTECA, CAL. <br /> - <br /> �- ° -IeS11 _2 - Phone Contractors Name $eriTLX2-56!±3- - <br /> J <br /> 2500 W. +Rumble Rd. Modesto Ca. 95350 <br /> TYPE OF WORK (Check}: NEW+WELL DEEPEN/ / RECONDITION / / DESTRUCTION /-7 <br /> i PUMP INSTALLATION '/ / PU'NP REPAIR '/ / PUMP REPLACEMENT /� <br /> k <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 11f SEWER LINES PIT PRIVY p <br /> SEWAE DISPOSAL FIELD �r - CESSPOOL/SEEPAGE PIT OTHER C <br /> 1'I - A �. <br /> INTENDED USE r TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ; Gable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other - X Rotary Type of Grout <br /> Other Other Information ' <br /> PUMP INSTALLATION: Contractor C <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / `/ ._State Work Done- <br /> PUMP <br /> one <br /> �h Y State Wank Dane <br /> PUMP UPAIR: / - - <br /> DF'zTRUCTION OF WELL: We,1 Diameter Approximate Depth <br /> De9cribe Material and Procedure <br /> i <br /> i 7 hereby agree to comply with all laws andregulationsof the San Joaquin Local. Health District <br /> f; 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 the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED Hennings Bros. ;',Drilling Cool Inc. TITLECC +C- <br /> (DRAW PLOT PLAN ON REVERSE SIDE) Bookkeeper <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED -BY <br /> DATE G� 3 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY�� '__ DATE INSPECTION BY DATE • ­ <br /> .. CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. I " <br /> W 1 A9A I 1 1 5/731M <br />