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SAN JOAQUIN LOCAL HEALTH DISTRICT 'x�' <br /> FOh OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> j Telephone: (209) 466--6781 fp <br /> + V APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.%I1- <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.herezn. described. This application is made in compliance with Sanj!Joaquin ; <br /> County Ordinance No. 1862 anal he Rules .and Regulations of the San Joaquin Local Health District. i <br /> JOB ADDRESS/LOCATION r t. <br /> TsAOKT_ON�_RD._�-700 SOU•ON WEST � i�Q� 2�0 CENSUS TRACT <br /> 1 SIDE e <br /> Owner's Name VENEMAN FARMS Phone 599-3596 <br /> Address A 8177 JACKTONE RD. - - <br /> City �' M i�rN_� <br /> ,I <br /> Contractor's Name BENNINGS EROS . DRILLING CO. INC . License # 290813 Phone 545-.1185 i <br /> 1525 PELANDALE AVE . MOD. 9 53 50 <br /> TYPE OF WORK (Check) : NEW WELL /X/ DEEPEN / RECONDITION /_/ DESTRUCTION /_7 rr3 <br /> PUMP INSTALLATION / f PUMP REPAIR / / PUMP REPLACEMENT <br /> Other ,/ / -- <br /> DISTANCE TO NEAREST: SEPTIC 'TANK /Spy+ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT /fOTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS . <br /> Industrial Cable Tool Ilia. of Well Excavation 24" <br /> Domestic/private Drilled Dia, of Well Casing 1011 N 1 <br /> Domestic/public Driven Gauge of Casing 3Z16 GA q ! <br /> _ Irrigation LX Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout C ement <br /> Disposal +X Other REVERSE Other Information Slab-by owner <br /> Geophysical ROTARYT Surface Seal Installed By: ('killer <br /> PUMP INSTALLATION: Contractor 4 ! <br /> Type of Pump .lu.�. ^� cS' H.P. S <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done F- <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply withlal.l laws and regulations of the San, Joaquin Local Health District <br />' and the State of California pertaining to or regulating well 'construction. Within FIFTEEN'aDAYS <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. wel.l in use.. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION r <br /> PRIOR TO GROUTING AND A FINAL;INSPECTION. <br /> SIGNED MNNINGS BROS. DRILLI . ,INC. BY TITLE SEC".' <br /> 1 (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I f <br /> APPLICATION ACCEPTED BY DATE 11 4- <br /> ADDITIONAL <br /> ADDITIONAL COMMENTS: ' <br /> PHASE II GR T INSPEGTION PHASETIT <br /> FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY ATE ? <br /> E-H. 1426 Rev. - I-74 jun+. / a/✓a � G�c,(.ee-a( X '�At ' 7 21 .� <br />