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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> c *;-Wephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,M_� <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued ±-Z2 <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 #1 <br /> JOB ADDRESS/LOCATION AIRPORT W&Y-NORTH OF WEST RIPON RD.- CENSUS TRACT <br /> O 7001 WEST OF AIRPORT WAY <br /> Owner's Name AL FONSECA J <br /> Phone 23 9-12 56 <br /> Address 22695 S• AIRPORT WAY City MANTECA <br /> Contractor's Name RENNIN GS BROS. DRILLING CO. INC. License #290813 Phone 545-118554- <br /> 3525 <br /> 45-1185 ..3525 PELANDALE AVE. , MOD. , CA. 953-50 <br /> TYPE OF WORK (Check) : NEW WELL jX_1 DEEPEN / / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR f / PUMP REPLACEMENT <br /> Other / / + <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 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 2 601 <br /> Domestic/private Drilled Dia. of Well Casing 1 ft <br /> Domestic/public Driven Gauge of Casing fGA <br /> X Irrigation X Gravel Pack Depth of Grout Seal <br /> Cathodic Protection X Rotary Type of Grout <br /> Disposal Other Other Information SLAB-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 /> DES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Q <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 HENNINGS BROS, O. ,INC. BY TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDR)f /' s <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INS#9CTION PHASE III/F NAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY , DATE <br /> 0, 77 _ <br /> E H 1426 Rev. - I-74 ,.�'� <br />