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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOh.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> 1 Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7 7 13 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued/0 <br /> } r (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 Joaquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> { <br /> JOB ADDRESS/LOCATION 16800 Rn Cottage- Av___e, Manteca, Ca CENSUS TRACT <br /> Owner's Name Merle E Thompson Phone 823 6431- <br /> Address <br /> 431Address 6800 So. Cottage Ave, City Manteca <br /> Contractor's Name ` .License Phone ?9 � <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/ / RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION /x/ PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other <br /> ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 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 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing Q <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. _�s <br /> PUMP REPLACEMENT: / / State Work Done <br /> f PUMP :REPAIR: / / State Work Done <br /> DES-TRUCTION OF WELL: Well Diameter Approximate Da th <br /> PP P <br /> Describe Material and Procedure <br /> i <br /> I hereby agree- to comply with all laws and regulations of the San Joaquin Local Health District <br /> t 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 /> WELL 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. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO'tVUTINQ AND A FINA INSPECTION. <br /> ( SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY �/ DATE fQA 7 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPEC IONPHAS III/FIN INSPECTION <br /> INSPECTION BY DATE INSPECTION BY PATE <br /> ro d,,. 01K �7� . 2M <br /> E H 1426 . Rev. 1-74 <br />