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SAN JOAQUIN LMAL-118ALTH DISTRICT <br /> FOB OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Perat No. 7S--_TP&eJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Z::E_7r_ <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/LOCATIONA TWO RIVERS RD\. MANTECA CENSUS TRACT <br /> Owner's Name D{ K PIRE Phone <br /> Address P.O. BOY 262CityVERNALIS <br /> Contractor's Name HENNINGS BROS. DRILLING CO. INC . License # 290813 Phone 522-1031 <br /> 2500 W. RUMBLE RD.., MODESTO <br /> TYPE OF WORK (Check): NEW WELL '/X-f DEEPEN '/_7 RECONDITION /_7 DESTRUCTION /_" <br /> PUMP INSTALLATION / PUMP REPAIR -7 PUMP REPLACEMENT 17 <br /> Other /% — <br /> DISTANCE TO NEAREST: SEPTIC TANK MQ SEWER LINES JQLY+ PIT PRIVY , <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT R � <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL -PUB-tM LL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation t; <br /> „ X Domestic/private Drilled Dia. of Well CasingZgti <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal t <br /> Cathodic Protection - Rotary Type of Grout BENTONIM <br /> Disposal Other Other Information SLAB- By OWNER <br /> Geophysical <br /> Surface Seal Installed B : DRILLER <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP 'REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Mat rial and Procedure /�,+€" 4J +'? .,i ce` /, 1111 <br /> I hereby agree to comply with alif`laws and regulat r us of ther San Joaquin Local Health District <br /> and the State of California pertaining to or regulating we11 ''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 BENNINGS BROS. DR . INC . BY &C1Z#4XZ1. SEC'. <br /> (DRAW PLOT PLAN ON(REVERSE SIDE} <br /> PHASE 1 FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE - -7S <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAV III/FINAL INSPECTION <br /> INSPECTION BY DATE r - INSPECTION BY �. DATE <br /> 1426 Rev. 1-74 <br /> h/75 2M <br />