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SAN JOAQUIN LOCA . HEALTH DISTRICT <br /> FG OFFICE USE: ' ,OVQ� 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No;7 --;)(OS�l <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued,7-AS,.7 <br /> (Complete In Triplicate) <br /> Application is Aereby 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 56p2 NQRTBILANp 41EOO14 CENSUS TRACT <br /> Owner's Name TED BEIER Phone 82�-7020 <br /> Address 887 CYPRESS AVE'. City , MANTECA <br /> Contractor's Name EENNINGS BROS. DRILLIN G CO. INC. License # 29081 -Phone -545-1-1-8.5- <br /> TYPE <br /> 4 -=11$ --TYPE OF WORK (Check) : NEW WELL /X-/ DEEPEN -1-7 RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other -/ 41 <br /> % <br /> DISTANCE TO NEAREST: SEPTIC TANK �rSEWER LINE PIT PRIVY <br /> 1r\ 409wow <br /> SEWAGE DIS OSAL FIELD 'CESSPOOL/SEEPAGE PIT OTHE� <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC W LL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation ft <br /> X Domestic/private Drilled Dia. of Well Casing1t <br /> 6 413 a q tii:_ <br /> Domestic/public Driven Gauge of Casing 60 W.A 11 <br /> r_ <br /> Irrigation Gravel Pack Depth of Grout Seal ff^t _ <br /> Cathodic Protection X Rotary Type of Grout Bentonite <br /> Disposal Other Other Information Flab--by- owner _ <br /> Geophysical Surface Seal Installed By. -„ drillers <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ?f r"—�"7�- c.•� ?Zr _ . H.P: - <br /> PUMP REPLACEMENT / / State Work bone <br /> PUMP -REPAIR: / / State Work Dome <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby. agree to comply with all laws and regulations of the San Joaquin Local Health Dis rict <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 TaGRQUTING <br /> ANQ A FINAL INSPECTION. <br /> SIGNED TITLE <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 INSPECTION P E IFINA INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> l��'L"� �,e;@,��/► � �per►.- �,�.�", C� a� 3 � <br /> E H 1426 Rev. 1-74 -- - �.1ywt -`_ - � 7"- 2M _ <br />