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SAN JOAQUIN LOC�ACHEALTH DISTRICT <br /> - FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7r5=. �lrJ <br /> THIS PERMIT EXPIRES 1 "YEAR FROM DATE ISSUED Date- Issued X75+ <br /> (Complete In Triplicate) <br /> Application is hereby made t 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 /> _ _ <br /> JOB ADDRESS/LOCATION 11257 East Highway 120, Manteca" r _ CENSUS TRACE' <br /> Owner's Name Wayne " Boggs - -- Phone 8236640 , <br /> Address 11257 EastEighwqy 120 Manteca Ca 6 City Manteca <br /> Contractor's Name - Hennings Brothers _ ds" License # 29081_3 Phone545-0221 i <br /> TYPE OF WORK (Check): NEW WELL �/ DEEPEN /� RECONDITION /� DESTRUCTION /� <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 -� <br /> Other - <br /> 1 <br /> DISTANCE TO NEAREST: SEPTIC.TANK SEWER LINES PIT PRIVY . <br /> SEWAGE' DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I Cable Tool Dia. of Well Excavation`s- i nr b+ <br /> Domestic/private I X. Drilled Dia. of Well Casing + <br /> �r.IR'Jlr� Domestic/public 'I Driven Gauge of Casing .250,. inch...po_ ly t_yrene <br /> Irrigation I X. Gravel Pack Depth of Grout Seal fifty feet <br /> Other t Rotary Type of Grout e.� <br /> Other Other Information <br /> i <br /> t - <br /> PUMP INSTALLATION: Contractor <br /> E Type of Pump H.P. <br /> F 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 /> t 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 /> info at on is tr h of my knowledge and belief. �L12 <br /> C.ontr. " Iic . 186808 T <br /> Sl"-- Manteca Plumbing 00 =- ",:';TITLE <br /> (DRAW PLOT PLAN ON.REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE -q-- , �"` <br /> rK <br /> r ADDITIONAL COMMENTS: <br /> P II ROUT INSPECTION PHASE II FINAL INSPECTION <br /> INSPECTION BY. a DATE 7-�9-_Z� INSPECTION BY DATE <br /> CALLP ON PRIOR TO GROUTING AND FINAL INSPE ION. <br /> FOR ,A GROUT .iNS ECTI � - <br /> 4 <br /> 7/72 1M <br /> E H 142b <br />