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w <br /> SAid JOAQUIN LOCAL HEALTH DISTRICT - <br /> FOR,-OFFI iJS 1601 E. Hazelton Ave. , Stockton, Calif: <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , Date Issued 2— <br /> (Complete <br /> (Complete In Triplicate) <br /> Y• <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 /> JOB ADDRESS/LOCATION B RENNON ED. / �i E�I�O CENSUS TRACT <br /> Owner's Name ANDY ROSSI DAIRY Phone 823-3955 <br /> F <br /> Address — . 17583- SOUTH -AIRPORT WAY „ MANTECA, CALIF.-99�336 city. <br /> Contractor's Name _.RenniingA Bros._ Drilling Co. , -Inc. License # 116322 Phone 622-564-1 <br /> TYPE OF WORK (Check) : NEW WELL /x/ DEEPENm,/ / RECONDITIONT7 _ <br /> 7 DESTRUCTION / <br /> ' PUMP INSTALLATION PUMP REPAIR/ _ <br /> I PUMP REPLACEMENT /_ <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY K <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool.. Dia. .of Well Excavation <br /> X Domestic/private Drilled ' Dia. -of Well Casings <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal Q� <br /> Other X Rotary Type of Grout - 6 <br /> Other Other., Information _ <br /> PUMP' INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMA' REPLACEMENT: / State Work Done . <br /> PUMP REPAIR: / / State Work Done <br /> ESTRUCTION 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 best of my knowledge and belief. - - <br /> SIGNED TITLEm <br /> D PLAN ON REVERSE SIDE <br /> FOR USE ONLY <br /> PHASE I 'a <br /> APPLICATION ACL ED BY FF DATE _ Z_� <br /> "ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA4Sj3=jWy4NAL INSPECTION <br /> INSPECTION BY DATE ]- 7SPECTION BY \ DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H' 1426 4/72 1M <br />