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SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781. ��j « 1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit N <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 Ordinanc No./,862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> S. E Corner Niway 120 & Airport Way <br /> Joy <br /> ADDRESS/LOCAT ON 220 East of Airport .Way 2501 South of HWL7dS4 TRACT <br /> Hunter Travel Service - Ed Ramsey Owner's Name y Phone 239-9505 <br /> Address ' 999 .W. Center St. -. Suite 5 City Manteca, Ca 95336;, <br /> Contractor's Name Hennings Brod. Drilling Co. , Inc• License # 290813 Phone 545-1185 <br /> 3525 Pelandale Ave . o esto, Ca.95350 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_% RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_ O <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE PINE DOMESTIC WELL 100 ' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation 12" <br /> Domestic/private Drilled Dia. of Well Casing 811 <br /> X Domestic/public Driven Gauge of Casing 160W Plastic <br /> Irrigation XGravel Pack Depth of Grout Seal 501 .Cement <br /> Cathodic Protection Rotary Type of Grout Cement <br /> Disposal Other Other Information <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 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 well in use. The above t�l <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 . DriTTIng Co. , Inc. <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> F R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: - <br /> P SE II GROUT INSPECTION PHASE I/FIN INSPECTI N <br /> INSPECTION BY DATE g INSPECTION B DATE <br /> E H 1426 Rev. - I-74 <br />