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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOS�OFFICI3 U E: 1601 E. Hazelton Ave., Stockton, Calif. <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_Tl6 <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 /> JOB ADDRESS/LOCATION 26-453 S.Airuort Wa_ •,dmf,, Sough of Almondwoo tCENSUS TRACT <br /> west side <br /> Owner's Name Albert Fonseca Phone 239-1452 <br /> Address 22695 2. Airport_Way CityManteca <br /> Contractor's Name Hennings Bros. Drilling Co. ,Inc. License # 29081 Phone 522-1031 <br /> 2500 W. Rumble Rd.. Modesto <br /> TYPE OF WORK (Check): NEW WELL. /V DEEPEN '/7 RECONDITION /7 DESTRUCTION / 7' <br /> PUMP INSALLATION / /PUMP REPAIR-/-7 EM <br /> PUMP REPLACENT /7 <br /> Other /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY / T 757 C <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER FoG� <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 24" (� <br /> Domestic/private Drilled Dia. of Well Casing 1 01 fin r, <br /> Domestic/public Driven Gause of Casing t Vrl <br /> X Irrigation x Gravel Pack Depth of Grout Seal <br /> Cathodic Protection x Rotary Type of Grout <br /> Disposal Other Other Informationgl n h- <br /> Geophysical Surface Seal Installed By_: ai cj I I Pr <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . / / State Work Done <br /> alf <br /> PUMP 'REPAIR: /7 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 anew 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 myknowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED _MNNINGS BSS DRILLING -CV.-.INC. BY SEC. <br /> DRAW PLOT PLAN ON REVEMB SIDE <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY !i!/ DATE 3�/ S " <br /> ADDITIONAL COMMENTS: <br /> PHASE II-AROUT INSPECTION PHASE IIi FINAL INSPECTION <br /> INSPECTION BY 4--- DATE INSPECTION BY A, DATE <br /> E H 1426 Rev. 1-74 2M <br />