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- <br /> *_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE"OI�FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77�33�J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,/,,7-2 <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 S.E. CORNER OF AVE D & AIRPORT WAY CENSUS TRACT <br /> Owner's Name ROOS BROS. Phone 823-5915 <br /> Address 28522 S. AIRPORT WAY City MANTECA <br /> Contractor's Name HENNINGS B_ ROS. DRILLING CO. .INC. License # 290813 Phone 522-1031 <br /> 2500 W. RUMBLE RD. , MODESTO <br /> TYPE OF WORK (Check) : NEW WELL/$/ DEEPEN /_/ RECONDITION /_/ DESTRUCTION /- <br /> AL <br /> PUMP INSTLATION PUMP REPAIR /—/ PUMP REPLACEMENT /- <br /> Other / / <br /> s <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER �OQ� t#Sr <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONSp '. <br /> Industrial Cable Tool Dia. of Well Excavation 26" <br /> Domestic/private Drilled Dia. of Well Casing 18" p_ <br /> Domestic/public Driven Gauge of Casing 40A N <br /> X Irrigation -,X Gravel Pack Depth of Grout Seal �1 <br /> Cathodic Protection X Rotary Type of Grout .. <br /> Disposal Other Other Information Slab-by Owner <br /> Geophysical /y/ Wow K, Surface Seal Installed By: .» <br /> PUMP INSTALLATION: Contractor <br /> //y Nn <br /> Type of Pump H.P. <br /> +U 710 <br /> PUMP REPLACEMENT / / State Work Done Uu <br /> PUMP _REPAIR: State Work Done t�M <br /> DESTRUCTION OF WELL: Well Diameter Appro at0� --7 6 1-7 <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 <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 INSPECTI \ <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED ., NC. BY TITLE SEC. <br /> W 1'h T PLAN ON RE RSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASX JIWFINALINSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> O <br /> 3/7 <br /> E H 1426 Rev. 1-74 � v P'�µ ' � r� S�' e. 4 6 2M <br />