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f�Q Jy/// SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> L <br /> I <br /> C3; USE: 1b01 E. Hazelton A(209}S�6&k67$1 Calif. <br /> Telephone <br /> APPLICATION FOR WELL :CONSTRUCTION OR PUMP PERMIT Permit No. T �/rJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3-Z6 '- (f- <br /> (Complete In Triplicate) <br /> Application is hereby Made t_ 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 5600 . E. ni?Rd- Manteca, CaliforniONSUS TRACT <br /> Phone 239-3525 <br /> Owner's Name P.G. Fr Properties Inc. <br /> Address 1 W e ter S a c Califor is <br /> 36 City Manteca <br /> DRILL[i�IG CO., INC. <br /> Contractor's Name License # Phone <br /> TYPE QF. WORK (Check) : NEW WELL I DEEPEN / I RECONDITION_/ I DESTRUCTION I? <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 O <br /> Industrial I Cable Tool Dia. of Well Excavation 1�9 <br /> j ✓Domestic/private ! L/Drilled Dia. of Well Caging <br /> Domestic/public ` Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other er Rotary Type of Grout �{ <br /> Other � � Other-Information ` o <br /> PUPIP INSTALLATION: Contractor <br /> I <br /> H•P• <br /> Type; of Pump <br /> PUMP REPLACEMENT: , / / State Work Done <br /> PUMP 'tEPAIR: /�/ State Work Done <br /> w <br /> E Approximate Depth <br /> DF--TRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> { I hereby agree to comply with all lags 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 /> TIT <br /> SIGNED <br /> SIGNED <br /> (DRAB LOT PLAN ON REVERSE SIDE <br /> ii FOR DEPARTMENT USE ONLY <br /> PHASE I- DATE ^-Z <br /> APPLICATION ACCEPTED BY V' <br /> ADDITIONAL. COMMENTS: <br /> PHASE GROUT INSPECTION PHA ,FINAL INSPECTION <br /> INSPECTION BY DATE - � INSPECTION BY DATES _ y 7y <br /> r CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br />