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- � SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR.OnICE usE. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> j Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 2 <br /> TIIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> f (Complete In Triplicate) <br />` Application is hereby 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 Jbaquin <br /> County Ordinance No.-.8.62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION T IP; D1 CENSUS TRACT 2-2-(9 -130-32- <br /> ri Phone <br /> Owner's Name , - � .�'� <br /> I <br /> Address 5$70 E. ALMONDWOOD AVE'. City " MANTECA <br /> Contractor's Name BENNINGS BROS. DRILLING CO. INC. .__ License # 2908'1 •Phone <br /> TYPE OF WORK (Check) : NEW WELL '/X/ DEEPEN/—/ RECONDITION / / DESTRUCTION /-T s� <br /> " PUMPJINSTA LATION / / PUMP REPAIR/ / PUMP REPLACEMENT /-7 <br /> Other /-7- <br /> DISTANCE <br /> /DISTANCE TO NEAREST: SEPTIC TANK 4+7 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 2 4" <br /> Domestic/private Drilled t Dia. of Well Casing 1(�tr <br /> Domestic/public Driven 'y° 'Gauge of Casing GA <br /> X Irrigation XGravel Pack Depth of Grout Seal <br /> Other X Rotary Type of Grout <br /> Other Other Information Slab— by owner <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ; H.P. a <br /> 'UMP REPLACEMENT: / / State Work Done <br /> PUMP stEPAIR: / / State Work Done <br /> G DF'�TRUCTION OF WELL: Welli. Diameter Approximate Depth <br /> Descqribe Material and Procedure • ' <br /> I hereby agree to comply with all laws and regulations of the San Joaquin ,Local Health District <br /> and the State of California' pertaining to or regulating well"construction. Within FIFTEEN DAYS <br /> j after completion of my work on a new well, I will .furnish the San Joaquin LocaL Health District a <br /> b <br /> 1 14ELL DRILLERS REPORT of the well and notify them efore putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED TITLE _ <br /> j W .PLAT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> n APPLICATION ACCEPTED .BY /49DATE <br /> ADDITIONAL C01,1IMENTS: <br /> PHASE II GROUT INSPECTION PHAS I• I/FINAL INSPECTION <br /> INSPECTION BY t DATE INSPECTION BY DATE 3-2 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> �2 <br /> V. 14 1A?A .5/731M <br />