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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: � lW1 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 22_F__ �p <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,9_/,�.�5}` <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 /> WELL #2 <br /> JOB ADDRESS/LOCATION AIRPORT WAY- NORTH OF W. RIPON RD. 24501 CENSUS TRACT <br /> WEST OF AIRPORT WAY <br /> Owner's Name AL FONSECA Phone 239-1256 <br /> Address 22695 S. AIRPORT WAY City MANTECA <br /> Contractor's Name HENNINGS( BROS. DRILLING CO. IINC . License # 290813 Phone 545-1185 S- <br /> 3525 PELANDALE AYE* - <br /> MOD.3 CA. O <br /> TYPE OF WORK (Check) : NEW WELL )$/ DEEPENi/ / RECONDITION /�f DESTRUCTION /_7 L� <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK -NON& SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD NONE CESSPOOL/SEEPAGE PIT _ OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 2611 <br /> Domestic/private Drilled Dia, of Well -Casing 1 '' <br /> Domestic/public Driven Gauge of Casing 4GA <br /> - Irrigation $ Gravel Pack Depth of Grout Seal <br /> Cathodic Protection X Rotary Type of Grout - <br /> Disposal Other Other InformationSLAB-BY OWNER <br /> Geophysical Surface Seal Installed By: <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 <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 NIN S R . I INC. B Y TITLE CC� t, 1 C_ lyric,1 <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I -7 <br /> APPLICATION ACCEPTED BY DATE �' / - <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I FI3AL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - <br /> 0/77 <br /> E H 1426 Rev. - I-74 <br />