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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> { <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No., <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) � <br /> Application is hereby made to the San Joaquin Local Health District for a permit to <br /> and/or install the work herein described. construct <br /> 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 L'Ot7ISE"AVE;. MANTECA TELL # 2 CENSUS TRACT <br /> Owner's Name Phone 8�3-59 $ <br /> Address 12162 E. LOUISE AVE. City MANTECA <br /> Contractor's Name KENNINGS BRO. DRILLING CO INC._ � � License # 116322 Phone522-5643 <br /> TYPE OF WORK (Check): NEW WELLd <br /> /W DEEPEN /_% RECONDITION /_� DESTRUCTION /� <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other l / <br /> DISTANCE TO NEAREST: SEPTIC UNK <br /> SEWER LINES PIT PRIVY 4 <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER �• <br /> INTENDED USE TYPE OF WELL <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> F Cable Tool Dia, of Well Excavation 2 0" <br /> Domestic/private k Drilled Dia. of Well Casing 1 rr X 6 <br /> Domestic/public ! Driven <br /> Gauge of Casing n !� <br /> Irrigation i Gravel Pack Depth of Grout Seal <br /> Other :X Rotary Type of Grout <br /> t Other Other Information <br /> b <br /> PUMP INSTALLATION: Contractor <br /> Type of Pumpa (� <br /> 4--h; cp H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done.. <br /> i. <br />,DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby agree to comply with 'al1 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 oni 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 TITLE <br /> ( (DRAW LOT PLAN ON REVERSE SIDE <br /> FOR <br /> PHASE I DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE Z � � <br /> ADDITIONAL COMMENTS: 1 <br /> PHASE II GROUT INSPECTION PHASE III/FINAL_INSPECTION <br /> INSPECTION BY DATE INSPECTION BY <br /> ���-� DATE <br /> CALL, FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M GA <br />