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j SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 _ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUS'- PER IT Permit No. Z7-3 <br /> / THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 1-1,,1-77 <br /> /// (Complete In Triplicate) 2Y6/-3Yo-03 <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 /> JOB ADDRESS/LOCATION HAYS RD.-1000t NORTH OF MC MULLIN-RD.-- _ CENSUS TRACT <br /> EAST SIDE <br /> Owner's Name AL FONSECA Phone _ 219-1256 <br /> Address 2&95 S. AIRPORT WAY City MANTEC:A <br /> Contractor's Name HENNINGS BROS. DRILLING CO-.,INC. --- License #290813 Phone ' 522_1031 <br /> 2 00 W. RUMBLE RD. MOD. <br /> t <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_/ RECONDITION f-1 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other / / <br /> CN <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVYFa;, F <br /> SEWAGE DISPOSAL FIELD — CESSPOOL/SEEPAGE PIT OTHER I <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 P all <br /> Domestic/private Drilled Dia. of Well Casing 18-5 <br /> Domestic/public Driven Gauge of Casing JQA <br /> _X Irrigation $ Gravel Pack Depth of Grout. Seal <br /> Cathodic Protection $ 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 /> 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 BENNINGS BROS. DRIMING5 MINC. BY TITLE -�i . <br /> SEC. <br /> ]]RAW POT PLAN ON REVERSE SIDE) 7-7 ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE �� �? <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTI F S /FIW INSPECTION <br /> INSPECTION BY DATE INSPECTION B DATE <br /> . . -7-7 <br /> 376 2ME H 1426 Rev. 1-74 <br />