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SAN JOAQUIN LOCAL HEALTH DISTRICT ,► <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Cal-if. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRKTIONF-OR PUMP PERMIT Permit No. ;7, '/,7Cv <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 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 /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 14022 South Austin Rd. CENSUS TRACT <br /> Owner's Name Mike Gikas Phone 823--4928 <br /> Address 14022 S. Austin Rd. City Manteca <br /> Contractor's Name Hennings Bros. Drilling Co. , Inc. License # 116322 phone 522-5643 <br /> 2500 W. Rumble Rd. MocLesto, a . 53 50 <br /> TYPE OF WORK (Check): NEW WELL /X/,_ DEEPEN / / RECONDITION /_-7 DESTRUCTION /-7AL <br /> PUMP INSTLATION / /j PUMP REPAIR / PUMP REPLACEMENT /- <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK 2 oa' v-' 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 2611 <br /> Domestic/private Drilled Dia. of Well Casing lbit (/I <br /> Domestic/public Driven Gauge of Casing 18 it x Mtn <br /> X Irrigation X Gravel Pack Depth of Grout Seal - <br /> Other X _ Rotary Type of Grout Cy- <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump —,-9 orifi- H.P. 4 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br />,DESTRUCTION 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 est of,� my knowledge and belief. <br /> SIGNED ' <br /> TITLE <br /> D L0PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY C` �, DATE <br /> ADDITIONAL COMMENTS: _ <br /> PHASE II G UT INSPECTION PHASE I�FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY --� DATE 9 <br /> CALL FOR A CRO INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />