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w _ _ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORAFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 ; <br /> APPLICATION FOR WELL CONSTRUCTION OR 'UMP PERMIT Permit No. Z44-- arIgq0 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Z_1/_Jc( <br /> (Complete In Triplicate) i <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herei described. This application is made in compliance with San Joaquin <br /> County Ordinance No.�Jl8b2�n Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION UNION,RD.- aiM2 SOUTH OF WOODWARD RD. _ CENSUS TRACT <br /> Owner's Name `E D MIL R _ Phone 823-3057 <br /> Address 20618 UNION- RD. City MANTECA <br /> Contractor's Name HENNINGS BROS. DRILLING=X0 'INC . License # 220813 Phone 522-1031 <br /> __2 00 W. RUMBLE RD., MODES,TO, <br /> TYPE OF WORK (Check): NEW WELL ;C7 DEEPEN -/— RECONDITION /7 DESTRUCTION <br /> PUMP INSTA_LLATION / j PUMP REPAIR /7 pump REPLACEMENT j7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK /OpoSEWER LINES loell PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER ' <br /> PROPERTY LINE - PRIVATE DOMESTIC'WELL 'l PUBLIC DOMESTIC WELL 3 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of WellExcavation 2n <br /> Domestic/private Drilled Dia. of Well' Casing 1 " <br /> Domestic/public Driven Gauge of Casing <br /> X Irrigation z . X i, • Gravel Pack Depth of Grout Seal � <br /> Cathodic Protection - T Rotary Type of Grout'-- 1 <br /> —Disposal Other Other Information <br /> ,. Saab--by- owner <br /> Geophysical Surface SeA l Installed By driller <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ' '}iii . '! A.P; <br /> PUMP REPLACEMENT: j_/ State Work Done ay# <br />-PUMP-'.REPAIR-: .�:_ :y/ �-'-Stets Work-Done= <br /> &ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Materialfand_Procedure. <br /> f f <br /> I hereby agree to comply with all laws and regulations of-the San Joaquin Local Health District 4 <br /> and the State of California pertaining to or regulating well cainstruction. 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 TO GROUTING AND A FINAL INSPECTION.' �� �`,•� <br /> SIGNED HENNINGSBROS. DRILLING CO. ,INC'.'~ _BY_ TITLE SEC. " <br /> (DRAW PLOT PLAN ON REVERSE ;SIDE <br /> F DE ARTMENT USE ONLY . A do att, 66o &d_, <br /> PHASE I <br /> 4 4 1 ,rJ <br /> APPLICATION;ACCEPTED DATE/a L. <br /> i <br /> ADDITIONAL COMMENTS:, <br /> tf PHASE II GROUT INSP ON PHASE III/FINAL INS ION <br /> - -- - - <br /> INSPECTION BY,^ DATE INSPECTION-BY; DATE <br /> `t E H 1426 Rev. 1-74 L-_�W&:,1,11-74 2M �► <br />