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SAk)AQUIN LOCAL HEALTH DISTRICT <br /> FOS OFFICE USE: 1601 E:-,Hazelton Ave: , `Stockton, Calif <br /> Telephone; (209) '-466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 7- 3� k <br /> I <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISS ,,,._. I <br />�pplication is herebY ued -S`'7 7 <br /> (Complete In Triplicate)made to the San Joaquin Local Health Districr a px mit o construct <br /> ind/or install the work herein described. This application is made in compliance with San Joaquin <br /> ounty Ordinance No. 1862 and the Rules and Regulations of the .San Joaquin Local Health District. <br /> rOB ADDRESS/LOCATION 21091 VAN ALLEN RD.--MILE NORTH OF RIVER RD2FSUS TRACT <br /> WEST SIDE. <br />)wner's Name M.R". SILVA - Phone 838-2643 , <br /> kddress y 21663 S VAN ALLEN RD`. City MANTECA <br /> 2ontractor's Name 'flENNINGS. BROS. DRILLING -'CO. $INC. License # 29081 Phone <br /> s <br /> 2500 W- RUMBLE RD, 2 .MOD'. <br /> TYPE OF WORK (Check) NEW WELL '/W/ DEEPEN /7/ RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / ,/ PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 10 SEWER LINES PIT PRIVY <br /> SEWAGE..DISPOSAL FIELD /fDr+- CESSPOOL/SEEPAGE PIT OTHER 10ELG- $O <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 11.0 <br /> Domestic/private' ;7- Drilled Dia. of Well Casing 6" PLASTIC <br /> _Gr.avel..Pack._ ._. __,__Depth. .of�-GroutgSeal- O_ALh. <br /> Domestic/public, Driven Gauge of Casing 1 0 <br /> Rotar T e of Grout BENTONITE <br /> ----Irri...gation�-.-_. .�.__. . __- . <br /> Cathodic Protection` y' yP ITE <br /> Disposal Other Other Information SLAB-BY OWNER <br /> Geophysical Surface Seal Installed B : DRILLER <br /> ?UMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> ?UMP REPLACEMENT: : / / State Work Done <br /> ?UMP -.REPAIR. / '/ State Work Done ! k <br /> )ESL.RUCTION OF WELL: Well Diameter ` �` L pproximate Depth _ <br /> Cj�ra 46.A911 Describe Mate ial Procedure e <br /> C hereby agree to comply with all laws and regulatio s of the .S Joaquin La al Health District <br /> ind the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on anew well, I will furnish the San Joaquin Local Health District a <br /> BELL DRILLERS REPORT of the well and notify them before putting the well- in use. The above <br /> Lnformation is true to the best of -my ,knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> -RIOR TO. GROUTING AND A' FINAL INSPECTION. r <br /> 31GNED TITLE <br /> (D W PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> ?HASE I DATE <br /> ePLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS <br /> PHASE II GROU , ITSPECTI N PHA II IN INSPECTI N <br /> INSPECTION BY ATE INSPECTION B DATE �' <br /> Ou/7�P�-�/.�J���-//!� ��r��� • <br /> 1/.77 2jA 1 / <br />