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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F <br /> FOL'. OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> - --- <br /> Telephone:p : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE -ISSUED Date Issued ,3-2f 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 Sari Joaquin <br /> County ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. r <br /> JOB ADDRESS/LOCATION Southland Avenue s CENSUS TRACT - <br /> Owner's <br /> RACT -Owner's Name Dr, Ra Dowell Phone 823-441+3 <br /> 440 E. Center St. <br /> Address City - Manteca, Cal. r <br /> Contractor's Name BENNINGS BROS. DRILLING CO. INC . License # 290813 Phone 522.-5643 <br /> 2500 W- Rumble Rd._ Modesto Cal. 95350 <br /> TYPE OF WORK (Check) : NEW WELL .IX/ DEEPEN '/—/ RECONDITION /_/ DESTRUCTION /? <br /> PUMP INSTALLATION / / PUMP REPAIR-/ / PUMP REPLACEMENT /_ <br /> Other / / d <br /> ,r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY � <br /> SEWAGE DISPOSAL. FIELD / U q " CESSPOOL/SEEPAGE PIT OTHER , <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation 1215 <br /> -x Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal _ rot _ <br /> Other XRotary Type of Grout . Bentonite-- -- { <br /> Other Other Information Slnb by owner <br /> . G <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> r <br /> PUMP- EPAIR:__a - - / / <br /> ' State Work Done <br /> A <br /> .DFIRTRUCTION 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 wel1 ''construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health -District F. <br /> WELL. DRILLERS REPORT of the well and notify them before putting the well in use. The above Lk <br /> information is true to the best of my knowledge and belief. <br /> SIGNED TITLE ?-�C,l-mar'. - -. <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED .BY (� _ DATE 2 <br /> ADDITIONAL C0�1MENTS: <br /> PF E II GROUT INSPECTION PHA$E,IIIjj1NAL INSPECTION <br /> INSPECTION BY T INSPECTION BY DATE -RS-1 <br /> CALL F'OR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPE ON. <br /> �/7��M F �� <br />