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�✓ SAN JOAQUI�N 1,0C-AL HEALTH DISTRICT <br /> FOE OFFICE USE: 1601 E:-!,Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 4666781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � } <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7 3gj7G <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., <br /> XB ADDRESS/LOCATION MANTHY RD.. f! S _ -- CENSUS TRACT <br /> 835--2593 <br /> Owner's Name DELMAR A�UCH I CONTRACTOR Phone <br /> Address 1369 EIINCOLN BLVD City TRACY <br /> HDFCN�iFi�SASRBTHERS DRILLING CO.., INCTaicense # 290813 Phone 522--1031 <br /> Contractor's Name RUPIME <br /> 95350 <br /> ' <br /> TYPE 'OF WORK (CYieZTc) :" NEW WELL X-1 DEEPEN_/_/` RECONDITION -/7_' DESTRUCTION /�.. <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT I�T <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ,, SEWER LINES PIT PRIVY <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 11=t <br /> X Domestic/private Drilled Dia. of Well Casing tt Plasti <br /> Domestic/public Driven Gauge of Casing 160 W11 <br /> Irrigation Gravel-Pack Depth of Grout Seal 501 <br /> Cathodic Protection - X Rotary- Type of Grout Bentonite <br /> Disposal other , Other Information Slab by oRne r <br /> Geophysical ` Surface Seal Installed -By: <br /> PUMP INSTALLATION: Contractor: - <br /> E Type of Pump <br /> I 1_ _ . <br /> PUMP REPLACEMENT: / / State Work Done } <br /> fState Work Don <br /> PUMP .REPAIR: — We/ /..,, <br /> Approximate Depth <br /> l DESTRUCTION OF WELL: „ Well Diameter <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^ Califo"'rnia pertaining.'to or,;regulating well construction. Within FIFTEEN DAYS <br /> after completion of my 'rwork on a new well,,,/will furnish the San Joaquin Local Health District a <br /> y 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 knowledge and belief. I WILL CALL FOR A GROUT I SPECTION <br /> t PRIOR TO GROUTING ANDA FINAL INSPECTION. ` <br /> SIGNED HENNINGS B. .; 'DRT fi .. INC. TITLE KPR 1 7E <br /> DRAW PZ T' PLAN 'ON RE FRSE SID ; is <br /> i f FOR DEPARTMENT USE ONLY f <br /> ' PHASE I '� mm <br /> k APPLICATION ACCEPTED BY DATE ��� <br /> ADDITIONAL CO <br /> ' HA �JI GROUT INSPECTION PHAS II/FINAL INSPECTION <br /> INSPECT-t'ON DATE Z INSPECTION DATE <br /> 3/76 24 <br /> E H 1426 Rev. 1-74 ��� .� <br />