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SAN JOAQUINLOCAL HEALTH DISTRICT <br /> FOB OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> —' Telephone: (209) 466.6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. S-34J <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 construct <br /> anti/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 CENSUS TRACT -- <br /> Owner's Name Monty Buck Phone 823--3063 <br /> Address 747 East Nile Ave. City Manteca <br /> Contractor's Name Hennings-Bros, Drilling Co. ,Tneo License # '22081 Phone 522-1031 <br /> f 2 00~W � 3 <br /> Rumbe Rd. --Mode sto --C-a-1if .�. <br /> k <br /> TYPE OF WORK (Check) : NEW WELL /V DEEPEN /-7 RECONDITION /-7 DESTRUCTION <br /> AL /—/ —PUMPl-T , <br /> PUMP INSTALLATION / / PUMP REPAIR/� PUMP REPLACEMENT IT <br /> Other I 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK 90 SEWER LINES o _ - PIT PRIVY <br /> SEWAGEIDISPOSAi�. ELD CES OOL/ EEPAGE PIT OTHER <br /> PROPERTY LINE : AIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> t INTENDED USE TYPE OF WLL CONSTRUCTION SPECIFICATIONS <br /> Industrial + Cable Tool Dia. of Well Excavatioq tl <br /> X Domestic/private Drilled Dia. o£. Well Casing <br /> Domestic/public Driven . Gauge of Casin812 GAA <br /> Irrigation Gravel Pack � --Depth of Grout Seal t <br /> Cathodic Protection X Rotary Type of Grout <br /> Disposal t Other Other Information ' ' Slab--by owner <br /> i Geophysical Surface Seal Installed 'By, <br /> PUMP, INSTALLATION: Contractor <br /> Type of Pump H•P• , <br /> PUMP REPLACEMENT: / / State. -Work -Done - <br /> PUMP ,REPAIR: / / State Work Done , <br /> DESTRUCTION 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 <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,b'est,of- my knowledge and belief. I WILL CALL FOR A'GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION.2 , <br /> SIGNED Hennings Bros. BRIliNg CO. Inc. by TITLE <br /> PLOT PLAN ON REVERSE SIDE <br /> OR DEPARTMENT USE ONLY ' <br /> PHASE I <br /> T .. __; -- � <br /> APPLICATION ACCEPTED= .�... =--�-�' <br /> DATE:- �= . . <br /> ADDITIONAL COMMENTS: 711 V <br /> F <br /> i PHASE II G S C N P I FINAL INSPECTION <br /> ' <br /> INSPECTION BY DA E S -' INSPECTION BY_. . ._,_ _. :--DATE..-- 0-L 1 J~ <br /> E F. R 7496 i2s3v_ 7_7G 2M <br />