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t. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F `R`. :F-'CE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.17- <br /> � ('s THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -2-7-,ZS <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 /> AIRPORT WAY <br /> JOB ADDRESS/LOCATION WELL # 1 MILE SOUTH OF g 120 CENSUS TRACT S � <br /> Owner's Name ALDO BROCCHINI Phone 823-2199 <br /> Address 6926 E WOODWARD AVE. MANTECA I CALIFORNIA City MANTECA <br /> Contractor's Name HE:NNINGS BROS. DRILLING CO. 3 INC. License # 116322 Phone 522-561+3 <br /> 2500 W. Rumble Rd. Modesto, California <br /> TYPE OF WORK (Check): NEW WELL /X� DEEPEN /-7 RECONDITION /-7 DESTRUCTION /- <br /> PUMP INSTALLATION /—/ PUMP REPAIR / / PUMP REPLACEMENT /7 <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 220 <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation _ X _ Gravel Pack Depth of Grout Seal <br /> Other X Rotary Type of Grout <br /> 3- <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <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 t the best of my knowledge and belief. <br /> SIGNED &- ,N_AA4L) TITLE <br /> .VAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY C, AT Z. <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P E I F AL INSPECT ON <br /> INSPECTION BY DATE INSPEC BY DATE —S-7,3 <br /> CALL FOR A GROUT INSPECTION PRIOR TO. GROUTING AND FINAL INSPECTION. <br /> E H 1426 fte .!Y 7/72 1M <br />