Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOL< OFFICE USE: 1601 E. Hazelton Ave.",•'Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 7- 13 7 1y <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 4-1-_-r_-77 <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 21091 VAN ALLEN RD.---MILE NORTH OF RIVER RDmj4SUS TRACT <br /> . I <br /> Owner's Name M.R. SILVA Phone 838--2643 <br /> Address 21663 S. VAN ALLEN RD . City MANTECA <br /> Contractor's Name HENNINGS BROS. DRILLING 'C0. ZINC. License # 290$13 Phone 522-1041. <br /> 2500 W. RUMBLE RD. , MOD. i <br /> TYPE OF WORK (Check) : NEW WELL '/7/ DEEPEN / / RECONDITION /_/ DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: . SEPTIC TANK `j Q/ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 70`+ CESSPOOL/SEEPAGE PIT OTHER GuELL- 5-0 <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 jjtl <br /> X Domestic/private �� Drilled Dia, of Well Casing 6" PLASTIC �} <br /> _. Domestic'public - e _ -Driven Gauge of Casing 160 WALL <br /> Irrigation. ; Gravel Pack Depth of Grout Seal 501 _ <br /> Cathodic Protection X _ Rotary Type of Grout BENTONITE <br /> Disposal Other Other Information SLAB-BY OWNER <br /> Geophysical Surface Seal Installed By: DRILLER _T <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> I <br /> PUMP REPLACEMENT: / / State Work Done <br /> _ I <br /> PUMP '.REPAIR: / / State Work Done i <br /> DE21 RUCTION OF WELL: Well Diameter pproximate Depth 3,?Describe Mate ia1 Procedure �� _ <br /> I hereby agree to comply with all laws and regulatio s of the 5 Joaquin Lo al 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 wellin 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 /> SIGNEDr, Co _ .TNr RY 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 /> PHASE II GROU , I SPECTI N PHA II IN INSPECTI N <br /> INSPECTION BY�& fit. ATE Z& 177 INSPECTION B r DATE Z <br /> D a1AP/Z� <br /> E H 1426 ReeGl/ff' �c�� /.� 1 177 . ; 2M <br />