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` _ k. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO£. *.OFFICUSE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> ��'� Telephone: (209) 466-6381 ] <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -3 <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 wade 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 S. Austin Rd- 1 mi S. of Hwy 120-East sideCENSUS TRACT <br /> Owner's Name Al Cardoza Phone 2_39-1018 <br /> Address 18816 S.Austin Rd. City Manteca <br /> Contractor's Name Hennings Bros. Drilling Co. Inc. License # 116 Phone 522•-5641 <br /> 2500 W. Rumble Rd. , Modesto <br /> TYPE OF WORK (Check): NEW WELL /� DEEPEN / { RECONDITION { DESTRUCTION /- <br /> PUMP INSTALLATION / / 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 /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool, Dia. of Well Excavation 221t X <br /> Domestic/private Drilled Dia. of Well Casing j A v` <br /> Domestic/public Driven Gauge of Casing 1z4" <br /> X Irrigation X Gravel Pack Depth of Grout Seal <br /> Other IL Rotary Type of Grout <br /> Other Other Information -. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. - <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP TtEPAIR: / / State Work Done _ <br /> .DFGTRUCTION 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 Joaquiai" oval 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. <br /> SIGNED % TITLE <br /> A&MT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I P/ <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL =DlENTS: s /C <br /> PHASE II G OUT INSPECTION PHASE I I FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 41 <br /> E H 1426 5/?31M I <br />