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* - SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO$. F CE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif.. r <br /> Telephone.: (209)X466,-678] <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '77`33.sA/' <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued . S-7 <br /> (Complete In Triplicate) <br /> Application is'".Aereby 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 wlth. San Joaquin , <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> .TOB ADDRESS/LOCATION . 6972 ,',Ea,st mise Manteca Between Main St <br /> UNSUS TRACT. <br /> C <br /> Owner's Name FRANK INDERBITZEN h . <br /> P one' <br /> Address`: 6972 EAST LOUISE. AVE. City :MANTECA <br /> k <br /> f <br /> Contrattor's Name Hennings Bros . Drilling Co. )Inc. 290813' 522-1031 <br /> License ; Phone <br /> 2 est um e . o es o , al. 95350 "'�" <br /> . ti <br /> TYPE OF WORK (Check) NEW WELL /XT DEEPEN -/_ RECONDITION /_ , DESTRUCTION`/ <br /> PUMP INSTALLATION / / PUMP REPAIR /�% PUMP REPLACEMENT /7 <br /> OtherLl <br /> DISTANC 0 NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _� OTHER <br /> PROPERTY LINE -__PRIVATE DOMESTIC WELL — PUBLIC DOMESTIC'W LLQ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS' . �. <br /> Industrial '. , t Cable Tool Dia, of Well Excavation n <br /> � X Domestic/private i Drilled Dia. of Well. Casing s i'C <br /> Domestic/public. Driven Gauge of Casing <br /> Irrigation I Gravel Pack Depth of Grout Seal 501U; <br /> Cathodic Protection i X Rotary Type of Grout <br /> Disposal 1Other Other Information a y owner " <br /> —Geophysical Surface Seal Installed By: driller <br /> PUMP INSTALLATI¢N: contractor <br /> Type of Pump H,P. <br /> PUMP REPLACEMENT: .-: .- i <br /> LA / / State Work Done <br /> PUMP °REPAIR: /�./ State Work Done <br /> STRUCTION OF WELL: Well D G r• Approximate Depth ':�� <br /> ` Describe laterial and 'Procedure <br /> I hereby agree to comply with all laws .and regulations of the San Joaquin Local Health i 'trici <br /> and the ,State .of Calif ornia.�pertaining to orregulating 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 sboye <br /> information is true to the best of- my knowledge and belief. I WILL CA.LL. F¢R A GROUT <br /> INSPECT"N <br /> PRIOR_TO GROUTING AND A FIN4L INSPECTION.. r <br /> ej <br /> SIGNS T t,llic ! J. <br /> (DRAW PLOT PLAN ON REVERSE <br /> 14 <br /> FOR DEPARTMENT USE ON <br /> PHASE I <br /> APPLICATION ACCEPTED BY � DATE �- 3/- <br /> ADDITIONAL COMMENTS: ' <br /> PHOV u75W-T, INSPECTIO)( PHA EINAL NSFE TIO <br /> INSPECTION BYDATE / 7 INSPECTION BY ZdZfL&f ATL ' 'VIM;i <br /> � <br /> E,H 1426 Rev. 1-14 C�+�P �d�.� s Jf� � � At •� 2�- �fY �/ i <br />