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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ICE '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,2 f__7/ <br /> (Complete In Triplicate) 5et 77-/y <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> ,9 <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 8285E, Vri+_ac Mega,_ Calif,, _.� _ CENSUS TRACT <br /> Owner's Name BiAnnhi Phone 023-' 3 <br /> Address <br /> City Manteca <br /> Contractor's Namehimp Ma-china= Corp, License # A290355 Phone 209_522;5027 <br /> TYPE OF WORK (Check) : NEW WELL /7 DEEPEN RECONDITION RECONDITION / / DESTRUCTION /7 <br /> PUMP INSTALLATION K PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 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 <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing .S <br /> X Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout ` <br /> Disposal Other Other Information v' <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor StanislauQ p & Mn <br /> Type of PumpTuMbintz.,Tohns+.nnH.P. _,00 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: /7 -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.knowled-ge ani e e L FOR A GROUT INSPECTION <br /> PRIOR TO�GPJqUTING AN FINAL INSPECTION. is ig ready for _ nspection. <br /> SIGNED <br /> -PT-LE <br /> DRAW PI T PLAN ON REVERSE SIDE + f <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY Y, CAMDATE <br /> ADDITIONAL COMMENTS; <br /> PHASE II GROUT INSPECTION PHAS II/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 126 Rev. 1-74 3/76 2M <br />