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F! w <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFZFFICE USE: 1601 E. Hazelton Ave. , tickton, Calif. <br /> r Telephone: (2tY9) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �]�r� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued • f <br /> (Complete In Triplicate) <br /> Application is hereby made totheSan 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 andithe Rules and Regulations of the 5an Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 500,1 Nort of French Camp Rd. on Jacktone CENSUS TRACT <br /> Owner's Name JAMES ROBELLO J ` Phone 9$2-4649 <br /> Address 14$66 S.:. JACKTONE RD. City MANTECA, CA. <br /> Contractor's Name Hennings BrOS. Drilling Co. y Inc. License j990813 Phone 545-1185 <br /> 3525 Pelandale Aire. Modesto Ca. <br /> TYPE OF WORK (Check) : NEW WELL- /-V , DEEPEN '/ / RECONDITION /_/ DESTRUCTION /-7PUMP INSTALLTION // PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> .0 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK " SEWER LINES loot PIT PRIVY <br /> SEWAGE DISPO�FIELD CESSPOOL/SEEPAGE PIT OTHER 25 _ <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL 1-02 PUBLIC DOMESTIC WELL--Irr-• we U6 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I Cable Tool Dia. of Well Excavation 1411 <br /> Domestic/private ! Drilled Dia. of Well Casing et <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation $ f .Gravel 'Pack Depth of Grout Seal <br /> Cathodic Protection X. Rotary Type of Grout <br /> i <br /> Disposal Other Other Information _ slab_ by owner l <br /> Geophysical Surface Seal Installed By: <br /> .- <br /> E PUMP INSTALLATION: Contr. _actor . <br /> Type of PumpH.P. b <br /> - - - - fir'------ <br /> PUMP REPLACEMENT: / / State Work Done i <br /> PUMP REPAIR: / / State Work Done _ <br /> DES•TRUCTTONOF�L�We�Di�et� 47.61" -�� ���� K"ate Depth <br /> t►- <br /> Describe Materiat and Procedure T <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 gALL FOR A GROUT INSPECTION <br /> IPRIOR TO GROUTING AND A FTNAT' INSPECTION. <br /> SIGNED HENNINGS BROS. DRILLING UD—. , INC. TITLE <br /> h1, (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I /_ � �� <br /> r APPLICATION ACCEPTED BY C� DATES/!! <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE - � : INSPECTION BY ATE 91- 7-'fie <br /> 4,ol:'R,U11,0 W6 c e a rte, A .t.®�.��„�,� rJ.r '�- 7 2M <br /> c; E H- 1426 Riau- 1-74 <br />