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a SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> r APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ,5 3l 3 <br /> (Complete._ In' Tripl°icate) <br /> Application is.bereby 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 /> & 7192 E__ .JOB ADDRESS/LOCATIO Wood-ard Rd-2nd lot W. of S Manteca Rd. CENSUS TRACT • <br /> South Side <br /> Owner's Name Harold Hahn Phone 823- 2 <br /> Address 620 Sierra St. city Manteca <br /> Contractor's Name Hennin s Bros. Drilling Co. Inc. License # 116322 Phone 522-564-3 <br /> 2500 W. Rum le Rd., odes o., Califr ..95350 <br /> TYPE OF WORK (Check) : NEW WELL /V DEEPEN /—/ RECONDITION /? DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY J <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �r <br /> Industrial Cable Tool Dia, of Well Excavation _ 12r' <br /> Domestic/private Drilled, Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal t <br /> Other X gRotary Type--of Grout 'Rentfmito <br /> Other Other Information <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 /> y � 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 %!, , TITLE s <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DP4RWNT USE ONLY <br /> PHASE I -7q- <br /> APPLICATION ACCEPTED DATE 73 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P I NAL INSPECTION <br /> IN�B DATE �+,ta INSP B DATE — <br /> E R GROUT INSPECT ON PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />