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:Z:l SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> og!'OFFICE USE: 1601 E. Hazelton Ave'. , Stockton, Calif. ! <br /> �- _ Telephone: (209) 466-6781 i <br /> • APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -517 <br /> � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to, the San Joaquin Local .11ealth District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 5440-E.1 Fig Avenue-Fig & Oleander CENSUS TRACT _ <br /> Owner's Name William And reeta - Smm Jarbee Builder Phone 522.-9312 (Jarboe; <br /> Address5440 E . Fig Avenue _ _ City Manteca <br /> C-57 <br /> Contractor's Name Hennings Bros. Drilling Co. , Inc. License #290813 PIcone522-5643 <br /> TYPE OF WORK (Check): NEW WELL �� DEEPIIV /_� RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION /-7 PUMP REPAIR /-7 PUMP REPLACEMENT <br /> Other Ll <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 A CONSTRUCTION SPECIFICATIONS 1 1 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> X Domestic/private ' Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> # Irrigation Gravel Pack Depth of Grout Seal <br /> :. Cathodic Protection �— Rotary Type of Grout <br /> Disposal Other - Other Information Sly. e <br /> Geophysical 'Surface Seal Installed B <br /> Drilling ,Co. Inc <br /> PUMP INSTALLATION: Contractor • <br /> Type�of 'Pump H.P. <br /> � z <br /> PUMP REPLACEMENT: l lI Stafe Work Done <br /> PUMP '.REPAIR: _,State Work-Done <br /> ES.TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe 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 /> 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 /> k.. PRIOR TO GROUTING AND A FIMb IN PECTION. <br /> SIGNED (deo- t461 TITLE S^ ems_ <br /> (DMW PLOT P W ON REVERSE SIDE <br /> F ?OR DEPARTMENT USE ONLY <br /> PHASE I ,~ -`/ <br /> APPLICATION ACCEPTED BY i, ' DATE <br /> ADDITIONAL COMMENTS: r <br /> PHASE Il G O 0 pHAM4 FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY _ DATE -/ <br /> ; t ~E H 1426 Rev. 1-74 -.-1-74 2M <br />