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r <br /> '''SAN*'JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE 1601 E. Hazelton Ave. , Stockton, Calif. <br /> f Telephone: (209) '466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued.��..-1�1 - <br /> (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 Joaquin <br /> k County Ordinance No. 1862 and the Rules_ and Regulations of the San Joaquin Local Health District, <br /> JOB ADDRESS/LOCATION Union & �CD-ff in Manteca CENSUS TRACT S-s <br /> Owner's Name gam Jarboe Phone <br /> --.522-9312 <br /> Address 2613 Standiford Ave . <br /> City Modesto <br /> Contractor's Name _ Henning_-_-Bross Drilling Co-7 Inc. License #116322 phone 522-5643 <br /> TYPE OF WORK (Check): NEW WELL A7 DEEPEN /-7 RECONDITION /-7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other �i _ N <br /> DISTANCE TO NEARESTSEPTIC TANK SEWER LINES PIT PRIVY <br /> • W <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER y <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ©' <br /> Industrial Cable Tool Dia. of Well Excavation 11'r -L <br /> X Domestic/private Drilled Dia. of Well Casing _ 3ic <br /> Domestic/public Driven Gauge of Casin1 CIA <br /> g <br /> ,.,,. . -- <br /> . Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information !�5/ <br /> f <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done 7 Zf-73 NO V4 0 eA 50L)NA.A(6.. <br /> PUMP 'REPAIR: State Work Done <br /> ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> F 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 /> after completion of my work on- a new well, I will furnish the San Joaquin Local Health District a <br /> iWELL 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. <br /> SIGNED i !i ,�� �� TITLE <br /> RAW PLOT PLAN ON REVERSE SIDE <br /> f FOR DEPARTMENT USE ONLY <br /> a <br /> PHASE I . <br /> APPLICATION ACCEPTED BY. ATE 17 <br /> ADDITIONAL COMMENTS: I - � <br /> PHASE II G ' SP CTION E / I INSPECT N <br /> INSPECTION BY DATE INSPE ATE <br /> f CALL FOR A GROUT INSPECTION PRIOR T0. GROUTING AND FINAL INSPECTION, - <br /> E H 1426 7/72 1M <br />