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T6,7t <br /> SAN JOAQUIN LOCAL HEALTR: DISTRICT ,, , +,• <br /> FOR�OFF C_E USE: _1601 E. Hazelton Ave. , Stockton, Calif. 4 ' <br /> Telephone : (209) 466-6781 ` <br /> ' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> F THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /-/- <br /> I Application is hereby made to the San- <br /> (Joaple eLon Triplicate} <br /> a permit <br /> and/or install the work herein described.q This applicationl HealthDrict istmade inrcompliancetwithnSan uJoaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 11132 S. Union Rd. <br /> CENSUS TRACT _ <br /> Owner's Name e <br /> Phpne <br /> Address 11132 S. Union Rd, }-�i 4 s M G!3 2)/' A11 <br /> City Manteca <br /> Contractor's Name Hennings Brothers416/ <br /> License # 3 Phone <br /> TYPE OF WORK (Check' )': NEW WELL t� <br /> AL. / DEEPEN /% RECONDITION /_% DESTRUCTION /� J <br /> .�,. ,.PUMP INSTLATION / 4 PUMP-REPAIR / 7/;--PUMP REPLACEMENT <br /> Other /? <br />,DISTANCE TO NEAREST: SEPTIC TANK '7 +ft SEWER LINES <br /> "r. . _.F 1PIT PRIVYN�. <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT= <br /> ' x i OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC=DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION,SPECIFICATIONS <br /> Industrial Cable Tool Dia, of <br /> Excavation <br /> X Domestic/private Drilled <br /> Domestic Dia. of Well-Casing \ x� <br /> /public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth'-of Grout Seal t <br /> Cathodic ProtectionRotar <br /> -"� ' -: y Type of '-drodt <br /> Disposal <br /> Other ' Other Information � r <br />__ I_Geophysical -- --- <br /> . Surface Seal Installed- By:" c <br /> PUMP INSTALLATION: Contractor f <br /> Type ofPump ! , <br /> H.P. <br /> PUMP REPLACEMENT: Stat �r C <br /> e Work Done 4 <br /> r <br />?UMP .REPAIR: State Work Done <br /> IESTRUCTION OF WELL: Well Diameter <br /> Depth; <br /> Describe,-.Ma-terial and Procedure Approximate ; <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health-District <br /> ind the State of California pertaining to or.regulating well •construction. Within FIFTEEN DAYS <br /> if ter completion of my wark_on a, new we11,'ITwi11 furnish the San Joaquin Local Health District a <br /> FELL DRILLERS REPORT=o€ 'the well11an8notify them befcre-putting the well- in use. The above <br />.n€ormation is true to the best of. my knowledge and belief. �,I WILL CALL FOR A GROUT INSPECTION <br /> RIOR TO GROUTING AND A FINAL INSPECTION, ' - <br /> IGNED-_ a <br /> - - - T-ITLE r <br /> (DRA.W PLOT PLAN ON REVERSE SIDE) <br /> RASE -jFOR DEPARTMENT USE ONLY f <br /> I�''�..� � - f <br /> PPLICATION-A�HA� <br /> PTED BY _ _ ' `' "` = �'� " "`"�'` <br /> nnf' <br /> DATE <br /> DDITIONAL COTS: QS II GUT INSPECTTO <br /> INSPECTION BY HASE II/FINAL INSPECTION <br /> DATE 'f INSPECTION BY <br /> DATE /: -- 77 <br />�E H 1426 Rev. 1-74 �.� _ ~ . 1/77 <br />