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SAR9 :JOAQUIN LOCAL HEALTH DISTRICT <br /> FOf7OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 j <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76� JS�UJ <br /> . THIS.=PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued <br /> App� 30 3SCE °'� � (Complete In Triplicate) 22 off- <br /> ication 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�nd, ;he Rules and Rag ations o e San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Jackton Rd.- 2 NLzle North of G ayes Rd.' CENSUS TRACT <br /> Owner's Name 0. J. Pizza Mobile $23- <br /> 1428 <br /> PhoniHome 823-6031 <br /> Address 10301 E. Moffet. Rd. City Manteca, Cal <br /> Contractor's Name - ' Hennings Bros . Driiii`n4 Co: Inc: License 890$13 Phone -522-1031 <br /> 2500 West Rumble- Rd. Modesto, a afornia 95 <br /> TYPE OF WORK (Check): NEW WELL / DEEPEN -/7 RECONDITION 1-7 DESTRUCTION /7 <br /> PUMP INSTALLATION,./-7 PUMP REPAIR -/-7 PUMP REPLACEMENT /7 <br /> Other <br /> * ;O <br /> DISTANCE TO NEAREST: SEPTIC TANK -`oma SEWERrLINES , PIT PRIVY +W <br /> SEWAGE DISPOSAL FIELDdl <br /> , `CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL ; <br /> INTENDED. USE TYPE OF WELL 1. + � CONSTRUCTION SPECIFICATIONS " <br /> Industrial Cable Tool y Dia. of Well Excavation <br /> Domestic/private x. Drilled Dia. of Well. Casing x <br /> Domestic/public Driven,%,, r ,;,.,-..Gaugeof Casing UA <br /> ^ — Irrigation X Gravel 'Pack`-' Depth.of Grout Seal ..1 <br /> Cathodic Protection X Rotary Type of Grout �t <br /> Disposal Other Other Information a y oiemer <br /> Geophysical Surface Seal Installed B r <br /> PUMP INSTALLATION: Contractor ' <br /> 'Typeof Pump H.P. <br /> 4 <br /> PUMP REPLACEMENT: . / State Work Done p <br /> PUMP .REPAIR: % / State Work Done " <br /> PES;TRUCTION 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 /> SIGNEDHENNINGS BROS. . , INC . TITLE BY <br /> a DRAW PLOT PLAN ON REVERSE SIDE PR <br /> FOR DEP MENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ',,— <br /> ADDITIONAL COMMENTS: - <br /> P E T ROUT IN PECTI PHASE III INAL MSPECTION <br /> INSPECTION BY DATE INSPECTION BY AT <br /> Olk <br /> R u 1 L9F, ve _ s_7. �� _ ��__ V 1./7k 0M <br />