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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE- OFFICE USE: � 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ZL6-7 9tl21y <br /> /THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued 3-�G <br /> (Complete In Triplicate) <br /> Application is hereby made Flo 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 Joaquit <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> ! JOB ADDRESS/LOCATION 690„E.Louise Ave.-.1-mi East of Cottage CENSUS TRACT <br /> - South side <br /> Owner's Name Hilma Ml Stenmark Phone ' 823--487 <br /> r f. <br /> Address _ ,8690 E .�,Louise Ave. City Manteca <br /> � R <br /> Contractor's Name Henning sjBros. Drilling Co. ,Inc. License # 2'90813 Phone 52 -1.031 <br /> 2500 W:. Rumble Rd, Modesto <br /> TYPE OF WORK (Check): NEW WELL /$7 DEEPEN'/7 RECONDITION /-7 DESTRUCTION 17 <br /> PUMP 'INSTALLATION / / PUMP REPAIR 7 FUMP REPLACEMENT /7 <br /> Other /% — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAG T OTHER <br /> PROPERTY LINE •- PRIVATE DOMESTIC WELL DOMESTIC WELL ` <br /> INTENDED USE TYPE OF .WELL CONSTRUCTION SPECIFICATIONS O <br /> Industrial VE Cable Tool Dia. of Well Excavation 11 ” <br /> $ <br /> Domestic private Drilled Dia. of Well Casing 6" olastir <br /> Domestic/public Driven Gauge of Casing 160 wall <br /> IrrigationGravel Pack Depth of Grout Seal _ 501 <br /> Cathodic Protection --=, Rotary Type of Grout Bentonite <br /> f Disposal - # Other Other Information ' Slab by owner_ <br /> Geophysical Surface Seal Installed By: driller <br /> ( PUMP INSTALLATION: Contractor r <br /> s Type`.of Pump H.P. <br /> PUMP REPLACEMENT,: . / / ;-State Work Done <br /> . PUMP REPAIR: /7 State Work Done <br /> STRUCT_ION _OF WELL:: Well,, Diameter. Approximate Depth <br /> Describe Material and Procedure <br /> rI hereby agree to comply with all laws and regulat +ons of the San Joaquin Local Health District <br /> Viand. the State of California pertaining to or regulating well '-construction. Within FIFTEEN DAYS <br /> after completion ofmmy. work 'on a new well, I will furnish the San Joaquin Local: Health District a <br /> WELL DRILLER$ .REPORT. of, the:.weal and; notify., theta before putting. the..well. in.use.... The above <br /> i information is true to the-V"t-of- my knowledge and belief. I WILL CALL FOR A GROUT INSPECTI N <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> 3 SIGNED HENNINGS BROS DRILLING Co. , INC. BY TITLE c SEC• <br /> i (DRAW PLOT PLAN ON REVERSE SIDE <br /> s <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> rAPPLICATION' ACCEPTED DATE ' <br /> ADDITIONAL COMMENTS <br /> PHAS U GET-3 -INSPECTION PHASE III/FINAL. INSPECTION <br /> INSPECTION BY ATE. 7 INSPECTION BYZ DTE S <br /> e -127 <br /> I E H 1426 Rev. 1--74 _ __ h/75 2M <br />