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SAN JOAQUIN LCCAL-J EALTH DISTRICT <br /> FOF *OFFICE USE 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 24-_2Z <br /> ' THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date_ Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a Permit to construct <br /> acid/or install the work herein described. This'appiication 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 'M NORTH oF Ila ,12 PENSUS TRACT <br /> t ST SIDE <br /> Owner s Name ROBERT MATHIAfi _ Phone _ .$-71+6� <br /> Address 17327 S . ILAN ALLEN ED, <br /> City" 'MANTECA <br /> Contractor's Name License # ' 29081 Phone 22. 1 011 <br /> MO <br /> TYPE OF WORK (Check): NEW WELL.',g DEEPEN ,/_7 RECONDITION /_7 DESTRUCTION .f7 <br /> f ` <br /> PUMP INSTALLATION J / PUMP REPAIR I PUMP REPLACEMENT / f ' <br /> Other / . <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER at-W-O" <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of ell Excavation _ 1aIr - <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public P Driven ----Gauge of Casing _ 12 ' GA <br /> _ <br /> Irrigation *� Gravel Pack Depth of Grout Seal 1, <br /> Cathodic Protection Rotary Type of Grout <br /> _ y yP ' <br /> BPntnni t:P <br /> Disposal Other Other Information blah:, her_ nti npr <br /> Geophysical Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump H.P. ti <br /> PUMP REPLACEMENT:, Ll State Work Done , <br /> PUMP +REPAIR: <br /> /_7 tate Work Done <br /> ,' ._ <br /> ES•TRUCTTON OF WE Well Diameter Apprdafimate 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. I WILL CALL FORA GROUT INSPECTION <br /> PRIOR TO GROUTING AND _A FINAL INSPECTION. . <br /> SIGNED RENNIN GS BROS. DRILLING CO. INC. BY TITLE SEC. <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE ' <br /> ADDITIONAL COMMENTS: <br /> PH&WIIAROUT INSPECTION PHASE :III INSPECTIO <br /> INSPECTION BY DATE G INSPECTION BY DATE <br /> �li7Ei De.. 9-7A - -/ 1�v/R� nv <br />