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~ SAN JOAQUtN LOCAL HE H -DISTRICT <br /> FOfi OFFICE USE: <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-.6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 75-z),L�?td <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -&L <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> Viand/or install the work herein described. This application is made in compliance with San Joaqutn' <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Between Trahern and end of So. Manteca Rd.CENSUSOil So. Iftatemn itdTRACT <br /> . <br /> Owner's Name Frank R. Machado Phone 823-4854 <br /> Address 26234 South Union Rd. City ' M n.te ca., Cal <br /> t <br /> Contractor's Name Hennings Bros. Drilling CQ. Inc. + L �enaf #290$13 phone 522-1031 <br /> TYPE OF WORK (Check): NEW WELL , DEEPEN '/ RECONDITION /_7 DESTRUCTION f-7 <br /> PUMP INSTALLATION/ / PUMP REPAIR-/-7 PUMP REPLACEMENT %j <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK 2001 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 201 Old well <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 1211 <br /> XX Domestic/private Drilled Dia. of Well Casing 6 wPI-537-1s <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal c� <br /> Cathodic Protection - Rotary Type of Grout Bentobite �' <br /> Disposal Other Other Information 6-LaS 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: /7 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 Y <br /> PRIOR TO GROUTING AND A _FINAL INSPECTION. <br /> SIGNED __.__.__� TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ^ <br /> APPLICATION ACCEPTED BY ' ' DATE <br /> ADDITIONAL COMMENTS <br /> f4ME MI GROUT INSPECTION PHASE I FINAL INSPECTION <br /> INSPECTION B35WKS., DATE - INSPECTION BY DATE -61- <br /> ."""' <br /> E H 1426 Rev. 1-74 <br />