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a�f SAN JOA HEALTH DISTRICT <br /> QUIN LOCAL , <br /> FOE. FFICE USE: 1601 E. Hazelton..Ave,. , Stockton, Calif. <br /> Telephone: .` (209) 466-6.781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l'YEAR FRON.tDATE 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 I in compliance with San Joaquin <br /> County'Ordinance No. 1862 and the Rules and Regulations of the .San -Joaquin Local Health District. , <br /> 10793 SOUTHLANDBETWEEN PRESCOTT & <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name ELWOOD COOPER Phone $23^2017 <br /> MANTECA CAL. <br /> Address . <br /> 6 .16 E. NORTHLAND. _ ` . Citq' r,, ._ ' <br /> . Contractor's Name. HENNINGS BROS . DRILLING CO. , 1NC : . ` License290$13 Phone 22 <br /> -1031 <br /> 25 71Mbb TU, , MIL95350 f <br /> TYPE OF WORK (Check): NEW WELL 'DEEPEN /� RECONDITION �T DESTRUCTION %f <br /> PUMP INSTALLATION / / PUMP REPAIR ,/ Pump PUMP REPLACEMENT <br /> Other j/7 <br /> .DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY �. <br /> ' SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER Q <br /> I� PROPERTY LINE- PRIVATE DOMESTIC WELL"—. PUBLIC DOMESTIC WELL v <br /> INTENDED USE TYPE OF WELL CONSTRUCTION .SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> XX Domestic/private Drilled Dia. of Well Casing - `V <br /> Domestic/public Driven Gauge of .Casing 12 Ga <br /> Irrigation Gravel Pack Depth of Grout' Seal 501 ._ <br /> Cathodic Protection 7 ` Rotary Type of Grout Bentonite <br /> Disposal Other ,.r Other Information Slab by owner <br /> Geophysical Surface Seal Installed `B : i r <br /> r ��/s7iN� <br /> PUMP INSTALLATION: Contractor <br /> Type :of Pump <br /> H.P. <br /> TUMP REPLACEMENT: ., / / State Work Done <br /> PUMP 'REPAIR: /? :State Work Done <br /> ri OG�,v �'�c-L &77�' i <br /> f <br /> DESTRUCTION ,OF WELL: Well Diameter '' A proximate Depth /° <br /> Describe Material. and Procedure <br /> I hereby g co agree to l with all laws and. regulations of the San Joaquin Local. Health District <br /> comply <br /> and the State of California pertaining to or regulating- well'-construction. Within lIFTEEN 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 othe -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 <br /> PRIOR TO- GROUTING 'AND A FINAL INSPECTION. BY: 2 <br /> .SIGNS HENN GS BROS. DR ANY., INC• TITLE BKPA <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <r <br /> PHASE I R.E <br /> APPLICATION ACCEPTED BY DATE <br /> ADDiTIONAL' COMMENTS: <br /> PHASE II GRO INSPECTION - PRASE IIIIZINALZNSPECTION 6 <br /> INSPECTION BY� DATE �/� ��'��� INSPECTION BY ATE <br /> 6;� G✓✓�L G Gni FG ry d r vike _ <br /> 214 <br />