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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1603 E. Hazelton Ave. , Stockton, Calif, <br /> Telephone: (209) 466-6781 �z i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. t� <br /> { <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date IssuedZr�$ 5 <br /> I (Complete In Triplicate) ��(-7e^ <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/ ' <br /> 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 WELL # 1 (LOUISE�AVENUE-/ MANTECA CENSUS TRACT <br /> i <br /> Owner's Name e,ncAn'I m - Phone 823-5978 <br /> Address 62 ELouise City Manteca <br /> Contractor's Name Hennings Bros. Drilling Co. , Inc. License # 1J-6322 Phone 522-5b43 <br /> TYPE OF WORK (Check): NEW WELL /3f 'DEEPEN /7 RECONDITION /__7 DESTRUCTION _ <br /> PUMP INSTLATION J PUMP REPAIR / / PUMP REPLACEMENT <br /> AL /7 <br /> Other / / <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES PIT PRIVY <br /> SEWAGE ,DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER o <br /> b <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial : Cable Tool Dia. 'of Well Excavation <br /> Domestic/private € Drilled Dia. of Qell Casing 1 ATX 16ft <br /> Domestic/public Driven Gauge of Casing 16n <br /> F _— Irrigation l Gravel Pack Depth of Grout Seal ' <br /> Other ice` Rotary Type of Grout F <br /> i Other Other Information <br /> PUMP INSTALLATION: Contractor A G <br /> Type of Pump. -�ua�,. <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done 0� <br />,PUMP REPAIR: _ _ _ /�./ State Work Done- - <br /> ESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with Call 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 E <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a d <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 TITLE <br /> (DRAW LOT LAN ON REVERSE SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: — <br /> PHASE .II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY �.Q DATE S�-,� 7 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. . j <br /> E H 1426 <br /> 7172 1M {',�� <br />