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.. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F0 OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) PPell <br /> Application is hereby made to the San Joaquin Local Health District for a permit to cons truct/ ^Oldeet <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 15550 S. Airport Way CENSUS TRACT <br /> Owner's Name Sylvan0 Pestano Phone 823-3930 <br /> i <br /> Address 15550 S. Airport Way City Manteca <br /> Contractor's Name Hennings Bros. License # Phone <br /> Z�O�t3 t%�-�-t\ <br /> i <br /> TYPE OF WORK (Check) : NEW WELL /-/ DEEPEN /_/ RECONDITION /_/ DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /- <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK Lj SEWER LINESSS' PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS G{ <br /> Industrial Cable Tool Dia. of Well Excavation 2' <br /> �L Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing Sc�. p.\3_C Q <br /> Irrigation i,� Gravel Pack Depth of Grout Seal <br /> Cathodic Protection _ _ Rotary Type of Grout \?, ,,A -e <br /> Disposal Other Other Information <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 knowledger,and belief. I WILL CALL FOR A GROUT INSPECTION <br />?RIOR T_Q GROUTING AND A FINAL INSPECTION. <br /> SIGNE TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT IRSVECTION PHASE III FINAL INSPECTAOIJ <br /> INSPECTION BY DATE INSPECTION BY / DATE <br /> E H 1426 ev. 1-74 /"`�' ` <br />