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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave., Stockton, Calif. <br /> 1. Telephone (-�W9) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _25r, <br /> (Complete In Triplicate) <br /> Application is hereby de 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 /> W ELL-03 <br /> JOB ADDRESS/LOCATION AIRPORT WAY--NORTH OF W. RIPON RD.3 42001 CENSUS TRACT <br /> WEST OF AIRPORT WAY <br /> Owner's Name AL FONSECA Phone 239-1256 <br /> Address 22695 So AIRPORT WAY City MANTECA <br /> Contractor's Name BENNINGS BROS . DRILLING CO. INC. License # 290813 Phone 545-1185 <br /> 3525 PELANDALE AV 5350 <br /> Nr, <br /> TYPE OF WORK (Check): NEW WELL T/- DEEPEN / / RECONDITION / DESTRUCTION /-7 _ U <br /> PUMP INSTALLATION / / PUMP REPAIR f / PUMP REPLACEMENT <br /> Other / / i <br /> DISTANCE TO NEAREST: SEPTIC TANK NONE SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD NONE CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation 2 6" <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of- Casing SGA <br /> X Irrigation $ Gravel Pack Depth of Grout Seal <br /> Cathodic Protection $ Rotary Type of Grout -- <br /> Disposal Other Other Information SLAB-BY OWNER <br /> Geophysical Surface Seal Installed By: *+ <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 to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED HENNINGS BROS. DRI . ZINC . BY TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I n � <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSI>ECTION PHASEIII/ INAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. - I-74 <br /> 6/9/ 2M <br />