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SAN 'JOAQUIN LOCAL HEALTH DISTRICT ~� <br /> FO&.OFFICEOS;,- 1601 E. Hazelton Ave. , Stockton, Calif.( <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.`��-1�1 W <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 &aquin Local Health District. <br /> JOB ADDRESS/LOCATION MTG A- CENSUS TRACT <br /> Owner's Name Budge Brown <br /> Phone � 823.-541 <br /> Address 847 E . .Woodward city , Manteca, Cal. <br /> k Contractor's Name Hunni.ngs Bros. Drilling. Co. , lnc .' License # 290813 phone 522-1031 <br /> 25QO W, <br /> Rumble Rd. Modes o xCa <br /> _ - <br /> TYPE OF WORK (Check): NEW WELL DEEPEN '/? RECONDITION f7 DESTRUCTION f7 <br /> PUMP INSTALLATION f / PUMP REPAIR/-7 PUMP REPLACEMENT f7 <br /> Other <br /> ADISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> F PROPERTY LINE - PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia.. of Well Excavation11 <br /> e, .gyp <br /> Domestic <br /> /private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing l <br /> Irrigation Gravel Pack Depth--df Grout Seal 0 1� . <br /> Cathodic Protection XX- Rotary Type of Grout Cemen <br /> Disposal Other Other=Information a > <br /> Geophysical �� Surface Seal Installed By: Hennings a; <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. i <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP-`.REPAIR: /% 'S tate 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 3 <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 /> PRIOR TO GRO NG AND IN INSPECTION. <br /> IGNED 7 <br /> TITLE <br /> RAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: j <br /> PHASE IT ROUT INSPECTION PHASE JM[FINAL INSPECTION / <br /> INSPECTION BY DATE 1 $`- INSPECIffON BY ZDATE - 6 <br /> E IFA/2"6 ^ �ReV 674eNHin�s, cfilCol - - u/yyHAtd <br />