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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F_09tOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. a <br /> Telephone: (209) 466-6781 <br /> ' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date IssuedL �2p_ u_ <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. .I <br /> 2--7- <br /> JOB <br /> 2 JOB ADDRESS/LOCATION N2W. CORNER OF S.MANTECA RD. & WOODWARD MaNSUS TRACT <br /> PARCEL D <br /> Owner's Name P.G. FRY PROPERTIES Phone 239-3525 <br /> Address 1 1 50WEST CENTER ST'. City MANTECA, , <br /> Contractor's Name EENNINGS BROS. DRILLING CO. ,°INC. _ License # 290813 Phone 522-1031 <br /> - - - - -_ 2500 W. FUMBLE_ RD. , _MOD. <br /> - - F, <br /> TYPE OF WORK (Check) : NEW WELL A7 DEEPEN/7 RECONDITION /7 DESTRUCTION /7 (_0 <br /> PUMP INSTALLATION / / PUMP REPAIR /-7—pump REPLACEMENT 1 i <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES PIT PRIVY i,�ous :rt <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 11n <br /> X Domestic/private Drilled Dia. of -Well Casing --571 - --__ ' <br /> Domestic/publicDriven Gauge of Casing 12 GA <br /> Irrigation..,, a,a...i �_-_.__- Gravel- Pack ;�, Depth of'Grout Seal <br /> Cathodic Protectiort7`! lRotary Type of Grout Bentonite <br /> I Other Other Information <br /> Slab-by ©rawer <br /> Disposal ' .F �,.: S -- - <br /> GeophysicalL Surface Seal Installed BX: Driller <br /> <x . <br /> PUMP INSTALLATION; Contractor i <br /> R ' <br /> ` 1 <br /> p` Type of-Pump r H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> z illi <br /> PUMP .REPAIR: /7 State ,Work Done <br /> y � <br /> pESTRUCTION 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 i <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new ufell, rl will furnish the San Joaquin Local Health District a; <br /> WELL DRILLERS REPORT of the well and riots°fy them before putting- the. well in .use.. The above <br /> information is true to the best of my�kr#owledge and..beiief._ 1I WILL CALL FOR A 'GROUT INSPECTION <br /> 'PRIOR TO GROUTING AN A FINAL INSPECTION. # <br /> SIGNED , TITLE <br /> ! RAW OT PLAN REVERSE SIDE <br /> NF1, FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY -- -- -- DATE 1 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS IX/,FINAL INSPECTION � <br />! INSPECTION BY DATE -/Q 7� INSPECT;ION,.-BY DATE /g-_90 <br /> �. <br /> i E H 1426 Rev. 1=74 1-74 2M h` <br />