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�' SAN JOAQUIN A17HEALTH DISTRICT <br /> ;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 76 <br /> .. <br /> n THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued _ �7 <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 ).o . 61 /2 d % CENSUS TRACT <br /> Owner's Name ANDREW ROSSI Phone $23-3955 <br /> Address 17659 S. AIRPORT WAY City MANTECA) CAL. <br /> Contractor's Name HENNINGS BROS. DRILLING CO. , INC . License #290813 phone 522-1031 <br /> UU WE, i <br /> TYPE OF WORK (Check) : NEW WELL/7 DEEPEN RECONDITION RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY ,t <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPQG PI�'VOW <br /> OTHE�74 <br /> t <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL Z f _ST IC WELL/® 7S' <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 13" t <br /> X Domestic/private Drilled Dia. of Well Casing tt <br /> Domestic/public Driven Gauge of Casing 12 Ga. <br /> Irrigation Gravel Pack Depth of Grout Seal 50t <br /> Cathodic Protection X Rotary Type of Grout Bentonite <br /> Disposal Other Other Information Slab_ a olme r <br /> Geophysical Surface Seal Installed BY: ctriiier <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br />. DES-TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Mat rial a d Procedure <br /> � - <br /> I hereby agree to comply wit al aws an regu tions o e San Jodvcal 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 CAL OR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED HENNINGS BROS. DRILLING CO. INC. TITLE <br /> D W PL T PLAN ON RE RSE SIDE) �' '' <br /> F DEPARTMENT USE ONLY <br /> PHASE I '0'"� <br /> APPLICATION ACCEPTED BY( DATE 4k, <br /> ADDITIONAL COMMENTS: <br /> PHAS I GROUT INSPECTION PHASE-W/FINAI, INSPECTION <br /> INSPECTION BY DATE - INSPECTION BY DATE Z <br /> 3x76 2M <br /> E H 1426 Rev. 1-74 <br />