Laserfiche WebLink
ut)ef SAN.Y`OA�IIIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: V %1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.'1ko--JQXW <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 Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 24421 S. AIRPORT WAY-1 ST PLACE SOUTH OF CENSUS TRACT <br /> W. RIPON RD. ,WEST SIDE <br /> Owner's Name JAMES LUCK Phone 82-1-5626 <br /> Address 24421 S. AIRPORT WAY City MANTECA <br /> Contractor's Name HENNINGS BROS. DRILLING CO. INC. License # 290813 Phone 522-1031 <br /> 2500 WL RUMBLE RD. , MODEST <br /> TYPE OF WORK (Check): NEW WELL jf DEEPEN/`77 RECONDITION /-T DESTRUCTION f7 <br /> PUMP INSTALLATION / / PUMP REPAIR/-7 PUMP REPLACEMENT /7 <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT O o <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 PLO <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing #!16 GA <br /> -�- Irrigation �- Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information &LAB ja OWNER <br /> Geophysical Surface Seal Installed BY: IR LLER <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP. ,REPAIR: / / State Work Done <br /> rDESTRUCTION OF WELL: Well Diameter Approximate Depth' <br /> Q i <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 GFQUT INSPECTION <br />' PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED HENNINGS jINC. BY TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ` y 7-41 <br /> ADDITIONAL COMMENTS <br /> PHASE JI GROUT INSPECTION PHASE FIN NSPECTION <br /> INSPECTION BY, 1 DATE INSPECTION B ATE r l <br /> E H 1426 Rev. 1-74 4/75 2M <br />