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} JgAN JOAQUIN LOCAL HEALTH-DISTRICT <br /> FOE. OEFE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.-------------- <br /> _Jd <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Dae Iss ed' 2_a&-,77 <br /> (Complete In Triplicate) x-57 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to cons <br /> truct <br /> and/or 'install the work herein described. This <br /> sapplication <br /> ofnJoa <br /> nis the Saede in an Joaquin <br /> quinpLocal eHeal.thwith SDistrict. <br /> County Ordinance No.- 1862 and.-the Rules andRegulations(aSS� ui®:J ate: { <br /> CENSUS TRACTMel <br /> � <br /> JOB,ADDRESS/LOCATION t <br /> - west side phone <br /> owner's-Name Stanislans Water Users <br /> Address- 5 . 9 <br /> 4 6 E. West Ripon Rd. City Manteca <br /> 813 <br /> Contractor's Name Hennings Bros. Drilling Co. Inc. License #290 _ Phone 22-10 1 <br /> 1_e . O' STRUCTION /7 <br /> • <br /> TYPE OF WORK (Check) : NEW WELL g7 DEEPEN/ / RECONDITION pj1MpEREPLACEMENT 17 <br /> PUMP INSTALLATION / / PUMP REPAIR /�/ <br /> Other /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK WER LINES PIT PRIVY C!� <br /> SEWAGE DISPOSAL FIE CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL ' .. PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of- Well Excavation 2611 <br /> , <br /> Domestic/private. Drilled Dia. of Well Casing 1 <br /> Driven Gauge of Casing TA [[-- <br /> � Domestic/public F <br /> Irrigation X. Gravel Pack Depth of Grout Sea1 _ -- ,Uc3.e�e- w C_ <br /> Cathodic Protection X Rotary Type of Grout `� <br /> Disposal <br /> Other Other Information �- y owner <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor H.P. a <br /> Type of Pump j ' <br /> PUMP REPLACEMENT: � _ State Work Done <br /> PUMP .REPAIR: / <br /> State Work Done <br /> DESTRUCTION OF WELL: . We'll Diameter <br /> Approximate Depth _ { <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San 3oaquin Local Health District Y. • <br /> j and the State of California pertaining to or ren 'Joaquin Local Health District a <br /> gulating well'construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San -Joaquin <br /> i WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> informatiion 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. BY TITLE SEC•17 T <br /> SIGNED HENNINGS BROS. D INC• <br /> DRAW Pt. T PLAN ON REVERSE SIDE) ' <br /> FOR ARTMENT -USE ONLY <br /> i PHASE I DATE <br /> F APPLICATION ACCEPTED B <br /> Y <br /> a <br /> 44- <br /> ADDITIONAL COMMENTS: PHASE FINAL INSPECTION <br /> PHASE II GROUT INSPECTION INSPECTION B ATE 77 <br /> INSPECTION BY DATE <br /> s 3/76 2M <br /> j <br /> E H 1426 - Rev. 1-74 <br />