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5 <br /> _r JOAQUIN LOCAL HEALTH DISTRICP"� <br /> FOFFFICE US : ,/ 160.__ E. Hazelton Ave. , Ste--kton, Ca--t . <br /> yy Telephone : . (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �� <br /> THIS PER14IT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued la::�� __M <br /> (Complete In Triplicate) <br /> pplication is hereby made to the San Joaquin Local Health District.,for a permit to construct <br /> nd/or install the work herein described. This application is.made in compliance with San Joaquir <br /> ounty Ordinance N9 1. 6 and_the3R les and Regulations of the San Joaquin-Local Health District. <br /> �'pj3�,'z. S�r�y ��r <br /> f OB ADDRESS/LOCATION H�Ty 3. 0 & S. McKinley Avenue CENSUS TRACT <br /> j wner's Name Frank Mendes z Phone $5$-299& <br /> f ddress 18389 S. McKinley Ave.'` City Manteca, Ca <br /> S <br /> ontractor's Name Hennings Bros. Drilling Cb. , Inc. License ,# 290813 Phone 545-1185 <br /> F <br /> 3525 Pelandale Ave. Modesto, Ca. 95350 <br /> YPE OF WORK (Check) : NEW Wq IL,L•::/$/DEEPEN / / RECONDITION /_/ DESTRUCTION <br /> "PUMPP STALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> ISTANCE TO NEAREST: SEPTIC TANK ; SEWER LINES :72 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT _ OTHER <br /> PROPERTY LINE -- P%JkTE DOMESTIC WELL __3_0 PUBLIC DOMESTIC WELL�� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 121' <br /> x Domestic/private Drilled Dia. of Well Casing $1f <br /> Domestic/public Driven Gauge of Casing 160 Walastic <br /> Irrigation X Gravel Pack Depth of Grout Seal 5 t <br /> Cathodic Protection —�— Rotary Type �of Grout �, y,i { <br /> t Disposal. Other Other Information _ Slab by owner <br /> Geophysical Surface Seal Installed By : <br /> y UMP INSTALLATION: - Contractor <br /> . Type of Pump <br /> F- <br /> b PUMP REPLACEMENT: / / State Work Done y <br /> UMP .REPAIR: / / State Work Done .. <br /> ES•T_RUCTION OF WELL: Well Diameter . Approximate Depth <br /> Describe Material and Procedure <br /> hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> nd the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> ifter completion of my work on a new well,kl will furnish the San Joaquin Local Health District a <br /> ELL DRILLERS REPORT of the well and notify them before putting the well in use.. The above <br /> nformation is true to the best of my knowledge and belief. I WILL L FOR A GROUT INSPECTION <br /> RIOR TO GROUTING AND A FINAL INSPECTION. <br /> IGN9WNNINGS BRAS. DRILLCO.-, -INC. TITLE BKPR <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> 'RASE I <br /> m.PPLICATION ACCEPTED BY . DATE' _ <br /> ,DDITIONAL COMMENTS: <br /> PHASE II GROUT IN5 CTION PHAS III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> R 74 lG')F ne„ - 1_7i. <br />