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• � SAN JOAQUIN LOCAIL REALTH DISTRICT <br /> FOR OF„t FSE USE: 1601 E. Hazelton Ave. ,_Stockton, Calif. <br /> Telephone: ,J209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> ^d THIS PERMIT EXPIRES ,1 YEAR FROM DATE ISSUED Date Issued :2 73 <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 Joaquin Local Health District. <br /> AIRPORT WAY <br /> JOB ADDRESS/LOCATION WELL # 2 j- MILE SOUTH OF KWY 120 CENSUS TRACT .- <br /> Owner's Name ALDO BROCCHINI Phone 823•-2199 <br /> Address 6926 E. WOODWARD AVE. CALIFORNIA City MANTECA <br /> Contractor's Name HENNINGS BROS. DRILLING CO. , INC. License # 116322 Phone522-561+3 <br /> 2 Knn .r Rulabl e Ed . Mrid e s .n a l <br /> 9 <br /> TYPE OF WORK (Check): NEW WELL /X7 DEEPEN /7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other / J <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER +� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 24W 'Opp <br /> Domestic/private Drilled Dia. of Well Casing 1611 <br /> Domestic/public Driven Gauge of Casing <br /> X Irrigation X _ Gravel Pack Depth of Grout Seal <br /> Other X _ Rotary Type of Grout <br /> Other Other Information <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 arid--.Procedure <br /> I hereby agree to comply with all laws and regulations of th�e,. San Joaquin ,Local Health District <br /> and the State of California pertaining to or regulating well c” truction. 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. <br /> SIGNED TITLE <br /> G? LOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY C DATE �- <br /> ADDITIONAL COMMENTS: <br /> Pa§h II OUT INSPE ON IJfINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY V DATE -- - 3 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />