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i <br /> SAN JOAQUIN L A HEALTH DISTRICT <br /> FOR'.:OFFICE USE: -1641 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 2- p_ <br /> (Complete In Triplicate) 2o?L -35'o -4)L <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 Satz Joaquin <br /> County Ordinance No.:1862 acid the Rules and Regulations of the San Joaquin Local Health District. <br /> �10�ADD``t��,'�'".."���-t6:�:�=t-�/'�'�-may• ' <br /> J•OB RESS/LOCATION Y BOVTLING GREEN LOT 29 CENSUS TRACT ' <br /> kRAYM[]S I REAL ESTATE <br /> Owner's Name Phone 823-311i-_8 ,-- <br /> P <br /> Address 544 E. YOSEMITE AVE. City ,MANTECA} CAL <br /> I <br /> Contractor's NameN S BROS DRILLING CO-6.--INC- _- . ., . License # 116322 Phone 522-5643 <br />`TIPE�OF-WORK"(CIe'c-.-): 'NEWYWEIX;X_[/-`' DEEPENS/7"/�RZE'CONDITION�/r7'UESTRUCTZON /7- <br /> PUMP INSTALLATION / / PUMP REPAIR '/ / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE ;TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I Cable Tool Dia, of Well Excavation 11+� <br /> XDomestic/private 1. Drilled Dia. of Well Casing - 6 ++ <br /> Domestic/public ! Driven ° Gauge of Casing �2. 9-A <br /> Irrigation I Gravel Pack Depth of Grout Seal - 501 <br /> Other i X Rotary Type of Grout Bentooi #A <br /> I Other Other Information ' Slab hy nLMpr. <br /> t� <br /> PUMP INSTALLATION,; Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> / - - - <br /> PUMP 'ZEPAIR: / - .,,State Work Done <br /> DF. TRUCTION 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 /> F information is true to the best of my knowledge and belief. <br /> k N- <br /> SIGNED� TITLE GP�PaL <br /> (D PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I e R <br /> APPLICATION ACCEPTED .BY - - -- — - - DATE AO <br /> ADDITIONAL COMMS-NTS: <br /> PHASE_II_ GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BYDATE / -10-,23 INSPECTION BY=awDATE J-2 <br /> . CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. (' <br /> F u IA?A EZ/71tu J� <br />