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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO}.°OFFICE USE: I 1601 E. Hazelton ,Ave. , Stockton, Calif. <br /> Telephone: (209) 466-x6781 <br /> i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued 7-25=7 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/oar install the worherein 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 /> .TOB ADDRESS/LOCATION j19425 S. Union Road Manteca CENSUS TRACT.. <br /> F <br />! Owner's Name Sohn S.1N Delores M. Correia Phone 823-4839 <br /> Address NNa S - .T�b _ L oLi�ti d r1 - City <br /> S BROS. DRILLING CO., INC. <br /> If Contractyor's Name License U Phone ; <br /> W. <br /> HUMBLE ROAD <br /> - <br /> TYPE OF WORK (Check) : NEW WELL IRI DEEPEN '/ / �RECONDITIQN_/ / DESTRUCTION /� <br /> r PUMP INSTALLATION /—/ PL'M,REPAIR-,/ / PUMP REPLACEMENT' /_7 <br /> O then <br /> DISTANCE TO NEAREST: SEPTIC TAiINK SEWER LINES far- PIT PRIVY <br /> SEWAGE DISPOSAL FIELD _ CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE I' TYPE OF:WELL (t ` ,, CONSTRUCTION SPECIFICATIONS <br /> Industrial - Cable-To-o--1 fDia of'We11'-Excavation jj ID-V <br />' X Domestic/parivatea. " Drilled Dia. of Well Casing <br /> Domestic/public ; 1 Driven , Gauge of Casing <br /> ^tr IrrigationV& Grave1-pack-v:- ,;Depth-df'Grout Seal <br /> Other Rotary Type of Grout rem ` P• <br /> c"Other Other °Information <br /> PUMP INSTALLATION: Contractok <br /> r- :Type of Pump` _ t .r, H.P. . <br /> PUMP REPLACEMENT: / / State ,Work Done ' <br /> PUMP UPAIR. "� /�/- State Work Dobe w_ <br /> �T3FGTRUCTION OF WELL; If,4ve1J7 Dzarieterr, s 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 Calif6rnia pertaining to or regulating well ''construction. Within FIFTEEN DAYS <br /> ' ?after completion of myl.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 toTthe best of my knowledge and belief. <br /> i `SIGNED <br /> (P&W PLOT PLAN ON VERSE SIDE) �T <br /> f <br /> FOR DEPARTMENT USE ONLY <br /> F €PHASE I <br /> 'APPLICATION ACCEPTED v � DATE <br /> !ADDITIONAL =MNTS: J <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATPrj'--X ";1yr INSPECTION BY oZWQA, DATE <br /> L--CALL-FOR_-A GROUT- INSPECTION-PRIOR-TO GROUTING AND FINAL- INSPECTION..-�. - <br /> E.H 1426 I� 5/733M0-4 <br />