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l / SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS*,OFFICE USE: 1601 E. Hazelton Aye. ,1 Stockton, Calif. <br /> Telephone: {'269) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �W <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 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 in compliance with San Joaquin; <br /> County Ordinance No.. 1862 and the Rules and Regulations of the San. -Joaquin Local Health District. <br /> 28128 S. TWO RIVERS RD.•--01MI SOUTH OF <br /> JOB ADDRESS/LOCATION D. 0 1200t OFF ROAD ON EAST gIDE f CENSUS TRACT <br /> Owner's Name BERT' VAN DYK Phone -821-5286 <br /> Address 28128 S . TWO RIVERS RD. City MANTECA <br /> Contractor's Name HENNINGS BROS. DRILLING CO. ,INC License # 2 081 Phone 522-1031 <br /> l 2 00 W. RUMBLE RD. MOD. .. <br /> TYPE OF WORK (Check): NEW WELL -A7 DEEPEN -/7 RECONDITION F7 DESTRUCTION /_7 <br /> PUMP INSTALLATION/ / PUMP REPAIR I PUMP REPLACEMENT <br /> Other L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY _ <br /> SEWAGE DISPOSAL FIELD CgSSPOOL/SEEPAGE PIT' <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL 00-AxINTENDED USE TYPR OF WELL =' CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. -of Well Excavation 2 ++ <br /> Domestic/private Drilled Dia, of Well Casingt1 <br /> Domestic/public Driven Gauge of Casing - GA <br /> � — 16 <br /> Irrigation _ Gravel Pack Depth of Grout Seal <br /> Cathodic Protection X Rotary Type of Grout - <br /> Disposal Other Other In€ormation• flab- by owned; ' <br /> Geophysical Surface Seal Installed B - <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: , / / State Work Done <br /> y .r- <br /> PUMP ,..REPAIR: <br /> /7 .State Work Done <br /> DESTRUCTION 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 <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED S B INC. BYTITLE SEC. <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ` f <br /> APPLICATION ACCEPTED BY DATE ' <br /> ADDITIONAL COMMENTS.- <br /> PHASE <br /> OMMENTS:PHASE I GROUT, INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTIONB17/ DATE �� 7 INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 � ,• � 4` i�o <br /> v 4/75 2m <br />