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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued )4 �-a?-A5` <br /> (Complete In Triplicate) -Zz`f— <br /> Appli6Ation 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. 1862 and the Rules and Regulations of the. San Joaquin .Local health District. <br /> JOB ADDSS/L©CATION- <br /> REN QW., CORNER OF -S. MANTEC,g,_ RD. W00T)WA 1) BNFNSUS, TRACT - <br /> ' <br /> Owner's Name _ PlG. FRY PR0ajj„�'IES PARCEL C Phone 232-15215 <br /> Address 1150 W. _CENTER ST'. k City - ' MANTECA <br /> f ' <br /> Contractor's Name HENN.INGS BROS. DRILLING CO. INC.. License # 2 81 Phone -1 <br /> 2 00 W. RUMBLE RD. MODESTO 31, <br /> % <br /> TYPE OF WORK (Check): NEW WELL-/&C7 'DEEPEN.J-7--RECONDITION°'/_7"' DESTRUCTION f7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR F7 PUMP REPLACEMENT /7 <br /> Other <br /> 4 <br /> DISTANCE TO NEAREST: SEPTIC TANK 130t SEWER LINES -130' PIT PRIVY house <br /> / SEWAGE-DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELLIQ_ PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation n y <br /> Domestic/private Drilled Dia. of Well Casing `_ <br /> Domestic/public Driven _ <br /> Gauge of Casing 12 GA <br /> Irrigation r Gravel Pack Depth of Grout Seal 5Q8 <br /> Cathodic Protection X Rotary `Type of Grout BENIM <br /> Disposal ' Other Other Information _ -- <br /> BY OWNER <br /> —Disposal <br /> s��aA�- <br /> I - Surface Installed BY: DRILLER <br /> PUMP INSTALLATION: Contractor <br /> Type of.Pump H.P. .- <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP `.REPAIR:r . /7 State Work Done <br /> ESSTRUCTION ..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 /> SIGNED BENNINGS BROS. -'DRILLING CO. I INC-. BY TITLE SEC:, A <br /> t. (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 'wt t t DATE �! -28 S^ <br /> ADDITIONAL COMMENTS: - <br /> PHASE 11 GROUT INSPECTION PHASE III/FDO! INSPECTION <br /> INSPECTION BY DATE d(INSPECTION BY DATE 7 <br /> 's E H 1426 Rev. 1-74 1-7 L. ?U <br />