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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE;OFFICE USE: 1607 E. Hazelton Avg. , Stockton, Calif. <br /> Telephon&°: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> A_ THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (3 V Q 2= S -H_I_�fc"'my 4- # (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local health District for a permit to construct a <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 Saar Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION N� of Nz of NW-1, Section 21. East side of CENSUS TRACT / 7-�?�BTbs <br /> US 99••: access road, t. north ot Verigin i <br /> Owner's Name CelPril industries , Inc Phone ' 823-1738 <br /> Address 211 Oak Street, P .O. Box 2215 City ' Manteca <br /> Contractor's Name Henning Bros . Drilling Co. License # 290813 phone 522-1031 <br /> TYPE OF WORK (Check): NEW WELL '/Z DEEPEN '/ RECONDITION /_77 DESTRUCTION /-.7 <br /> Lu <br /> PUMP INSTALLATION Ll PUMP REPAIR/7 PUMP REPLACEMENT ' 17 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK°.110- SEWER LINES 110 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 100 . .CESSPOOL/SEEPAGE PIT OTHER, j <br /> PROPERTY LINEZ PRIVATE DOMESTIC - 'PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> IndustrialCable Tool Dia. of Well Excavation <br /> Domestic/private X Drilled Dia. of Well. Casing. <br /> Domestic/public :Driven Gauge of Caring <br /> X Irrigation Gravel Pack Depth of Grout Seal., 50 .tt. <br /> Cathodic Protection Rotary Type of Grout BenPonite:: - <br /> Disposal Other - Other-Information <br /> Geophysical Surface Seal Installed 'By: Owner <br /> PUMP INSTALLATION: _ Contractor j'/Not -determined <br /> Type .of- Pump - .SUbmersibl� H.P. , <br /> PUMP REPLACEMENT: . s / / S.tate-.Work"-Done <br /> PUMP ,REPAIR: / / -State Work Done <br /> DESTRUCTION OF WELL: Well Diameter - - Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all- haws -and regulations -of- the- San Joaquin L-ocal'-Health Disttict <br /> and the State of California pertaining to or regulating well"construction. Within FIFTEEN DAYS <br /> after completion of my work on a new-,we11__. 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..-. Theabove <br /> information is true to he•best.of my,,kxt_oial.edge,and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUTING-AWA 4INAL INSPECTION. <br /> SIGNED_.. _ A . ... _ = �,. � » �.��-a.m � <br /> " TiT1LA <br /> _. - PLOT PLAN ON REVERSE SIDE) <br /> R-DEPARTMENT USE ONLY <br /> PHASE I .—- <br /> APPLICATION ACCEPTED BY DATE. <br /> ADDITIONAL COMMENTS: , <br /> PHASE II 0 °I PCT -.. PHASEII FINAL <br /> INSPECTION <br /> INSPECTION BY "ATEA Jg- ]Z Y INSPECTION BY DATE �p2J ,6 <br /> E A U ILIA b- _ Y / 1t77K 9M <br />