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!/r Lf///'✓- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR ,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> V`w Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT . Permit No. 26- Z Z..24J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued ,-6 <br /> S.• 1e,-H -Qct (Complete In Triplicate) <br /> Applic6tion--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 ADDRESS/LOCATION N% of N- of NA, Section 21. East side of CENSUS TRACT ,/'??- <br /> US <br /> RACT /g?-US 99 access Road, t. nortri of verigin <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 # 290813phone 522-1031 <br /> -- i <br /> h <br /> TYPE OF WORK (Check): NEW WELL/W DEEPEN 17 RECONDITION /7 DESTRUCTION /-7- <br /> ` <br /> PUMP INSTALLATION PUMP REPAIR /-7 PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO'NEAREST: SEPTIC TANK' 11-0 SEWER LINES 110 PIT PRIVY 61 <br /> SEWAGE DISPOSAL FIELD 100 CESSPOOL/SEEFAGE PIT OTHER <br /> PROPERTY LINE ) PRIVATE DOMESTIC 'WELL L' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial 'Cable Tool Dia. of Well Excavation 11 <br /> X _ Domestic/private o X ._:Drilled Dia. of Well'Casing 6 5 S <br /> Domestic/public Driven Gauge of Casing 10 <br /> Irrigation Gravel Pack Depth of Grout Seal. 50 .'ft. <br /> Cathodic Protection Rotary Type of Grout Bentonite' <br /> Disposal OtherOther Information ' <br /> Geophysical °� �, .Surface Seal Installed By: Owner <br /> PUMP INSTALLATION: .Contractor, <br /> "Type of_-Pump ghmersa_b7_P. ,:_ H.P. <br /> PUMP REPLACEMENT: ! I I Sate Work YDo e'-_...�- .,.,_ .,..,.,...,,..---,..,,,. .,..__„,_—...__�.., _._._,-,— <br /> pUM'P.REPAIR: :-State Work Done <br /> DESTRUCTION OF WELL: vWell Diameter- -- - Apor-ogima-a 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;'Lknowledge_,and belief. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TOG 0 A FINAL INSPECTION. <br /> SIGN - <br /> I PLOT PLAN ON REVERSE SIDE <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED B - }'DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE T SP ON PHASE I IN NSPECTION ` <br /> INSPECTION BY °DATE 6 INSPECTION BY -DATE r2 i <br /> 3? u l L?A vs _ I_71. � � / OCe-� h/7q 2M <br />