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SAN 30A�ilIN LOCAL HEALTH DISTRICT <br /> FOtiOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> $ Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL -CONSTRUCTION OR PUMP PERMIT Permit No. a- �,/ir% <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued a- �7Z <br /> I (Complete In Triplicate) 5 <br /> Application is .hereby mr <br /> made to the San Joaquin Local health District fora permit to construct <br /> and/or install the work herein described. This application 'is made iu compliance with Sar: Joaquin <br /> County Ordinance No. 1862 and the 'Rules' and Regulations of the Sart Joaquin .Local. Health District. <br /> JOB ADDRESS/LOCATION 1$499 South Jacktone-4 Mile South of Hwy' 120 CENSUS TRACT <br /> ,4 . <br /> Owner's Name - Pete WintersPhone • 599-6690 Ripon <br /> Address . ..18499 So. Jacktone..Rd. Mantecar n a . <br /> City: ' <br /> Contractor's Name HenningsSrooss . Drilling" Co. , Inc: ` e # 290813 Phone 522.-1031 <br /> 2 00 Vries-Humble 'Rd. .. Mzlesro, Ca.��� .. . . <br /> TYPE OF WORK (Check): NEW WELL A7 DEEPEN '/7 RECONDITION /7 DESTRUCTION %f <br /> PUMP iNSTALLATION C/ PUMP REPAIR'/ PUMP REPLACEMENT %T <br /> � Other /% . <br /> i DISTANCE TO NEAREST SEPTIC ,TANK 100 t+SEWER LINES • PIT PRIVY <br /> SEWAGE;DISPOSAL FIELD CESSPOOL/S EPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL" 60 ' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Took, Dia. of Well Excavation T' <br /> X _ Domestic/private — Drilled Dia. of Well Casing - <br /> Domestic/public DrivenGauge_a€, Casing - - -- ga <br /> Irrigation ;d. Gravel-Pack- Depth of Grout Seal <br /> Cathodic Protection �� Rotary �` Type of Grout ' MnBentonite <br /> Disposal Other--I Other Information Slab by owner <br /> Geophysical Surface Seal Installed Byi driller .. <br /> PUMP INSTALLATION.- Contractor <br /> Type .6f Pump* H.P. <br /> PUMP REPLACEMENT: . L V State Work Done <br /> PUMP .REPAIR: /-7 :State Worts Done <br />� DES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agr a 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 FINAI; INSPECTION. <br /> SIGNED FEYNTNUd .::. 0. INC.. TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED Y DATE <br /> ADDITIONAL COMMENTS <br /> E PHASE II GROUT INSPECTION PHASE III AL NSPECTION <br /> (. INSPECTION BYx DATE IN PECTION BYATE <br /> E H 1426 "� Bev. 1--76 - A h/75 -2M <br />