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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209.) 466-6781 <br /> APPLICATION FOR WELL CONSTkUCTION OR PUMP PERMIT Permit No. _yfc <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date :Issued <br /> (Complete In Triplicate) <br /> Application is, hereby 'bade 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 Joaqui <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 5440 e . FIG AVE . MANTECA 6 CENSUS TRACT <br /> Owner's Name Mr. -& Mr's . WILLIAM H ,ANDREETTA Phone 823-4314 <br /> Address 2 MARIE St. _ <br /> _ City MANTECA <br /> Contractor's Name. <br /> c <br /> ense #-),df&4?fd Phone <br /> TYPE OF WORK (Check) : NEW WELL L#/ DEEPEN /_7 RECONDITION /7 DESTRUCTION /_ <br /> PUMP INSTALLATION [�J PUMP REPAIR / / PUMP REPLACEMENT /? <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC, TANK SEWER LINES PIT PRIVY <br /> ` SEWAGE DISPOSAL FIELD_,:-..p�"_CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL E 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 <br /> Irrigation -Gravel Pack Depth of Grout Seal � r <br /> . Other Rotary Type of Grout <br /> Other Other Information qP <br /> PUMP INSTALLATION: ' Contractor J <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> .PESTRUCTIO_N 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 /> i 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 /> k information is true the best of my knowledge and belief. <br /> SIGNED �1��.y TITLE_ <br /> (DRAW PLOT PLAN ON-REV ERSE _SIDE _ <br /> r PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE _szG <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING .AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />