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/ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i F0 FFICE USE: '/ 1601 E. Hazelton Ave, St-c kton, Calif. w <br /> y <br /> Telephone :p (209) 466-6. 781 <br /> j APPLICATION. FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1, YEAR FROM DATE ISSUED. Date Issuedl <br /> 1+ <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 'NI 1 6 and the R les and Regulations of the San Joaquin Local Health .District. <br /> �0 & S <br /> JOB ADDRESS/LOCATION WY -1, . McKinley Avenue <br /> CENSUS TRACT <br /> ' Owner's Name Frank Mendes Phone $5$-299k <br /> Address, - 183$9. S.. McKinley Ave. City Manteca, Ca <br /> Contractor's Name Hennings Bros. Drilling CO. , Inc. License # 290813 Phone 545-1185 <br /> ___3525 Pelandale Ave. 116desto.i Ca. 95350 <br /> TYPE OF WORK (Check) : NEW WELL /x/ DEEPEN / / RECONDITION / / DESTRUCTION /`T <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 W <br /> otherk - <br /> DISTANCE TO NEAREST: SEPTIC TANK 7W SEWER LINES PIT PRIVY <br /> SEWAGE}DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PTE DOMESTIC WELL ___3_0 PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 127 <br /> X Domestic/private ' X— Drilled Dia, of Well Casing $tt <br /> Domestic/public , Driven Gauge of Casing 160 Wall Plastic <br /> Irrigation 1 � Gravel Pack Depth of Grout Seal 501 <br /> Cathodic Protection Rotary Type -of Grout <br /> .Disposal. Other Other Information Slab by owner <br /> Geophysical Surface Seal Installed By: _ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> t PUMP REPLACEMENT. / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> 1 <br /> D.ES•TRUCTION OF WELL: Well 'Diameter Approximate Depth <br /> Describe Material and Procedure <br /> V <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 ML FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNMENNINGS BROS. DRILL .", C. TITLE �BKPR� <br /> (DRAW PLOT PLAN ON REVERSE SIDE) - -- <br /> FOR DEPARTMENT USE ONLY <br /> } PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT ,INS CTION PHAS III/FINAL INSPECTION <br /> INSPECTION BY iPATI INSPECTION BY DATE - f <br /> zf 2M <br />� E H '1426 Rev. • 1-74 <br />