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.� . <br /> SAN JOAQUIN LOCAL HEALTHDISTRIt'.T � <br /> AOR-'OFFICE CSE: V ' 1601"E. Hazelton Ave. , Stockton, Calif. <br />--- Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. /771J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to 1the San Joaquin Local <br /> 'described. <br /> 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 ,trhe Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION HW 2 e eCENSUS TRACT ' <br /> Phone 2 <br /> Owner's Name Manuel DeC <br /> ile % ! <br /> Address <br /> 1301$ -E'+- H,�y 120 - ,.• .'City Njan .ra <br /> License # Phone 5 <br /> Contractor's Name Hennings Bros. D it • - �- <br /> ��w <br /> 2 500 W.. Rumble'-, Rd.. Modesto ` <br /> _ /`T <br /> TYPE OF WORK (Check) : NEW WELLJxDEEpEN RECONDITION / <br /> PUMP INSTLATION '�J PUMP REPAIR I I PUMP REPLACEMENT I_T <br /> AL <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWERFLINES PIT PRIVY ` <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ OTHER . <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL '— PUBLIC DOMESTIC WELL O <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> _-,< Cable Tool Dia. of Well Excavation 22" <br /> Indus trial <br /> Domestic/private Drilled g' Dia. of Well Casing 1 <br /> Driven . _. Gau e ,of Casing.. .,_. _-- GA:..� <br /> Domestic/pub_l# <br /> Drive. - - <br /> '`` - Gravel Pack Depth of Grout Seal 0' <br /> X Irrigation <br /> Da_nemanf ea in— <br /> Cathodic Protection X Rotary is Type of Grout <br /> Disposal Other _ Other Information Slab•-by. prier <br /> Geophysical s Surface Seal Installed B d. i <br /> F INSTAL ON: Contractor :" ,�. H.P. <br /> Type of Pump. <br /> PUMP REPLACEMENT: /_7 State Work Done \# <br /> PUMP .REPAIR: / / State Work Done <br /> ' + '- �,. roximate Depth 4 <br /> DESTRUCTION OF..WELL: Well Diameter + PP p '"-'. <br /> t 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 wel1'canstructi6n.3LLW3thin FIFTEEN DAYS <br /> after completion of my work on a new well, I willfurnish 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 T GROUTING ANDA F INS TI <br /> TITLE <br /> SIGNED <br /> D 'R PLAN 'ON RE RSE 'SIDE) <br /> F DEPARTMENT USE ONLY <br /> PHASE I DATE - <br /> APPLICATION ACCEVTED BY <br /> ADDITIONAL COMMENTS: P I I/ NAL INSPECTIO <br /> PtWE II ROU II3SPEGTIO DATE <br /> fNSPECTION BY DATE INSPECTION BY � ` <br /> rt /76 2M <br /> , <br /> - <br /> E H 1426 Rev. ,l-74 r ... <br />