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/" R <br /> �,//' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. /,1tcJ <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 Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION S. E. Corner & Airport Way CENSUS TRACT <br /> Owner's Na Arnol Phone 823-.2633 <br /> Address 23400 So. Airport Way City Mantecae,Cal. <br /> Contractor's Name e �rill�ingCo. � Inc. ' License #290813 Phone 522-1031 <br /> 2500 'We s t R i mb e Rd. MoUesto, a 95350 <br /> s <br /> TYPE OF WORK (Check): NEW WELL /X7 DEEPEN/7 RECONDITION /_7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR 1-7—PUMP REPLACEMENT /7 <br /> Other E7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 701+ . PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSg(j%/SEEPAGE PIT OTHER <br /> 40i Corral <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL:--15' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 12" <br /> XDomestic/private X Drilled Dia. of Well Casing Syl <br /> Domestic/public Driven Gauge of Casing 12 ga <br /> Irrigation Gravel Pack Depth of Grout Seal 501 <br /> Cathodic Protection — Rotary Type of Grout �e itonite <br /> Disposal Other Other In-formation R1ab by owner <br /> Geophysical Surface Seal Installed BY: driller <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . <br /> / / State Work Done <br /> PUMP .REPAIR: /7 State Work Done <br /> DES-TT„RUCTION OF WELL: Well Diameter Approximate Depth - w <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 WILjqCALL FOR A GROUT IN PECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED NINGS BROS. DR , INC. TITLE SECT <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE Z <br /> APPLICATION ACCEPTED BYG5DAT$ <br /> ADDITIONAL COMMENTS: <br /> tMS.EaI GROUT INSPECTION PHA I FINAL INSPECT ON <br /> INSPECTION BY DATE—T-76 -9T INSPECTION BY DATE k k 9;S <br /> E H 1426 1 Rev. 1-74 <br />