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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton-fie. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 24-129*,." <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application 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. 1 62 and the Rules gncl Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION So. Manteca Rd. 4th house N. of W. Ripon RdCENSUS TRACT <br /> on WeST 6ide <br /> Owner's Name Hillary Hahn Phone 239 -942$ <br /> Address 23702 S. Manteca Rd. City Manteca, Cal. <br /> Contractor's Name Hennings Bros . Drilling Co. ) Inc. License #290813 Phone 522-1031 <br /> 2500 W. Rumble Rd. Modesto Cal 0 <br /> i' <br /> TYPE OF WORK (Check) : NEW WELL /T/ DEEPEN '/—/ RECONDITION /�/, DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT 17 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC:TANK 60V SEWER LINES •+ PIT PRIVY <br /> SEWAGE.DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHEROld Well. 251 ; <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ^ Cable Tool Dia. of Well Excavation 11 <br /> X Domestic/privateDrilled Dia. of Well Casing 11 lk <br /> Domestic/public A -Driven Gauge of Casing "l)i <br /> Irrigation . Gravel Pack Depth of Grout Seal 01 <br /> Cathodic Protection X Rotary Type of Grout Bentonite <br /> Disposal Other Other Information Slab by owner <br /> Geophysical a Surface Seal Installed By: Driller <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> v <br /> UMP REPLACEMENT: / / State Work Done �"� <br /> P / / State Work Done <br /> ESTRUCTION OF WELL: Well Diameter &,*' 4v-P;41-"`X AA-eA!!�e_ Approximate Depth O <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 HENNINGS BROS. DRILLING CO. INC. TITLE <br /> JA_4r,(­e— <br /> !'ITDRAW 'i. TPLAN ON REVERSESIDE <br /> OR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY f DATE �Jr <br /> ADDITIONAL COMMENTS: <br /> PHAS WltGROUTANSPECTION PHA INSPECTION <br /> INSPECTION BY ATE INSPECTION BY -DATE <br /> E H 1426 Rev. 1-74 �' yrs/ aJ eO l/-- _ 3/76 2M <br />