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SAN JOAQUIN LOCAL HEALTH DISTRICT I <br /> FOF OFF-ICE f <br /> SE: 1601 E. Hazelton Ave'. , ,Stockton, Calif. _�,•t <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 7/z7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 0 <br /> (Complete In Triplicate) <br /> Application'is Aereby made�'to the San Joaquin Local Health District for a perm t to construc c <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> Countj 'Ordinance No. 1862 and the Rules and Regulations of 'the San Joaquin Local Health District.. <br /> JOB ADDRESS/LOCATIONSEpAZI AVE_, I. - <br /> T OF AUSTIN RD. NORTH CENSUS TRACT <br /> -= -_ . SIDE <br /> Owner''s Name BIANCHI ENTERPRISES a Phone 82 -642 <br /> Address P.O. BOX 10 - City '' MANTECA <br /> y <br /> Contractor's Name HENNINGS BROS. DRILLIN G CO`.,� INC. License # 290813 Phone 45..7185 <br /> 3525 PELANDALE AVE. MOD. Y <br /> i <br /> TYPE OF WORK (Check) : NEW WELL /-X/ DEEPEN / / RECONDITION / / DESTRUCTION /7 <br /> j PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> } Other f / <br /> DISTANCE'TO NEAREST: SEPTIC TANK1200 f SEWER LINESI 2nn r PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> t PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> G Industrial Cable Tool Dia, of Well Excavation 26" <br /> f <br /> : Domestic/private Drilled Dia. of Well Casing 162 <br /> Domestic/public Driven Gauge of Casing <br /> X Irrigation Gravel Pack Depth of Grout Seal <br />` Cathodic Protection X _ Rotary Type of Grout <br /> :Disposal •"'._ Other ` "- Other Information SLAB-BY OWNER <br /> &Geophysical - Surface Seal Installed B <br /> F M <br /> PUMP INSTALLATION: .4 -_ Contractor <br /> Type of Pump ,� _ .._�_ �--. . aj 1j, P; <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP ,.REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diameter , Approximate"Depth - <br /> ;# Describe Material and Procedure' _ <br /> y <br /> I hereby agree to comply with all laws and regulations•' of the San Joaquin Local Health,,Distric`t <br /> and the State of California pertaining to. or regulating well 'construc_tion:~. Within\FIFTEEN°DAYS <br /> aftertcompletion 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 thgm before putti g`the'well 'in use. ° The above <br /> Ir <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. y <br /> SIGNED HENNINGS BROS. BYkG � �eeu TITLE �e r <br /> — DRAW PLOT PLAN. QREVERSE SIDE) _ <br /> FOR DEPARTMENT USE ONLY <br /> PHASE. I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PIIAS I/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE -141 <br /> 177. <br /> E H" 1426 � Rev. 1-74 <br />