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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTBON OR PUMP PERMIT Permit No. 77-1,214; <br /> THIS PERMIT EXPIRES 1 YEAR FR%M DATE ISSUED Date Issued 9-,').4-27 <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 Yeritas Ave.-20001 East of S.Manteca Rd. CENSUS TRACT <br /> Owner's Name LarT south side Aksland Phone <br /> Address 8282 E. Veritas Ave. City Manteca <br /> Contractor's Name Hennings Bros. Drilling Co. Trac. License # 290813Phone ' 5221031 <br /> 2 00 W. Rumble Rd. Modesto <br /> i <br /> TYPE OF WORK (Check) : NEW WELL '/x-7 DEEPEN/_/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK &W/ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT �THEW u2pj/ i/day <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 26" <br /> Domestic/private Drilled Dia. of Well Casing 1 ►' <br /> Domestic/public Driven Gauge of Casing <br /> _X Irrigation - X Gravel Pack Depth of Grout Seal <br /> Cathodic Protection X Rotary Type of Grout -. r <br /> Disposal Other Other Information, Slab-b oxa r <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 s true to the best of- my-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G UTING D NAL INS CTION. <br /> SIGNED TITLE <br /> DRAWL T PLAN 'ON RE ERSE SIDE) <br /> PHASE I FOR ATARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE Z <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE,;WFINA4.5,INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE,F_ Z�= <br /> E H 1426 Rev. 1-74 i C-s'n' Qi 3111-77 376 2M <br />