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SAN JOAQUIN LOCAL HEALTH DISTRICT "" a <br /> FOR OPFICE. USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 71 .1.3j w <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued is <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 19054 Suess C t. Manteca <br /> CENSUS TRACT <br /> Owner's Name R am Gresham Phone �_7S 7 <br /> Address 541 N. Lincoln Manteca Cal city Manteca ' <br /> Contractor's Name Hennings Bros. Drilling Co. ! Inc. License # 116322 Phone 522-5643 <br /> TYPE OF WORK (Check) : NEW WELL /17 DEEPEN /_/ RECONDITION /_7 DESTRUCTION_ /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP. REPLACEMENT /_7 <br /> Other ./ / <br /> DISTANCE TO NEAREST: SEPTIC TANK 5_'SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation tt <br /> Domestic/private Drilled Dia. of Well Casings <br /> Domestic/public Driven Gauge of Casing12 G,� N <br /> Irrigation Gravel Pack. Depth of Grout Seal <br /> Other - Rotary Type of Grout 07 <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor C? <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Wo bone <br /> PUMP-REPAIR: - / / State' Work Done <br /> ,RESTRUCTION 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 knowledge and belief. <br /> SIGNED , I TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I ------FUR EPAR MET USE ONLY •--------• <br /> APPLICATION ACCEPT Y DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I41AINAJ, INSPECTION <br /> INSPECTION BY DATE INSPECTION BY E <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M G <br />