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KY, <br /> / <br /> !!// SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r F'OF.:OFF+w�� 1j9-1:—. 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209)' 466-67$1 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. '3-309 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date Issued -173 <br /> (Complete In Triplicate) � <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> F 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 and Regulations of the Sana in La I I a h District. <br /> JOB ADDRESS/LOCATION 2ND PLACE NORTH OF DIVISION AT END OF CENSUS TRACT <br /> SOUTH MANTECA RD. 3 Sr Rd . IW7�4-4' <br /> Owner's Name DIANE STILLHORN Phone 823_�644 <br /> Address .7474 DIVISION RD. City MANTECA <br /> r Contractor's Name HEiVNINGS BROS. DRILLING CO. INC. License # 116322 Phone 522-564� <br /> W-.- Rtxmbl.e.:Rd. -:Modesto. __Ca <br /> TYPE OF WORK (Check) : NEW WELL /V DEEPEN '/_/ RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / J PUMP REPAIR '/ / PUMP REPLACEMENT /-7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK Q SEWER LINES ' p PIT PRIVY <br /> SEWAGE DISPOSAL FIELD,�� CESSPOOL/SEEPAGE PIT -OTHER <br /> �1�5-` <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia:,,of Well Excavation T+ <br /> X Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Ga <br /> IrrigationGauge Gravel Pack Depth of Grout Seal. s <br /> Other X Rotary Type of Grout <br /> Other Other Information 51ab_h,L comer <br /> - rl <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Wolk Dane <br /> PUMP UPAIR: / / State—Work Done <br /> ,DF�TRUCTION OF WELL: Well Diameter Approximate Depth y <br /> Describe Material' and Procedure - { <br /> t a <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District I <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 i <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. <br /> T <br /> SIGNED TITLEk <br /> OT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY � <br /> 4 PHASE I <br /> APPLICATION ACCEPT B C .. i \ 4 DATE <br /> ADDITIONA ; CO <br /> ROUT INSP�N - P T NAL INSPECT N <br /> INSPECTION' S DATEINSPECTION DATE <br /> CALL- FOR -GROUT •INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> V Yr 1114 <br />