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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> .Or,.OFFICP. US =. 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone. (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 82- 40 <br /> � <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 /> 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 /> 9-0'A 4 S <br /> JOB ADDRESS/LOCATION Woodward & Manteca Rds.- S. W. Corner Apprq�NSUS TRACT <br /> — 8236220 Home <br /> Owner's Name Qryjjjg PhillijDs Phone 823-1148Work _`� <br /> ow <br /> Address 1South Manteca Rd., City , - Manteca <br /> _ _ <br /> C-57 <br /> Contractor's Name y nn-i gs -Bros, D 111ing Co. , Inc_ License # 2_90813 Phone 522-564-1 <br /> ` J{ �. <br /> ! -"".�`z-'-� <br /> TYPE OF WORK (Check) : fNEW WELL 13V DEEPEN_! % RECONDITION f I DESTRUCTION /-7 '! <br /> i PU,IP INSTALLATION -7 <br /> PUMP REPAIR '/ / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC- TANK 00 f SEWER LINES PIT PRIVY <br /> el <br /> SEWAGE DISPO AL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> i INTENDED USE ' .TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial fi Cable Tool Dia. of Well Excavation 12 <br /> Domestic/private # Drilled Dia. of Well Casing ri <br /> Domestic/public Gauge of Casing 12 Ga <br /> Irrigation qQ� �_ Gravel Pack Depth of Grout Seal 50, <br /> Other - Rotary Type of Grout Bentonite <br /> Other Other Information Slab by Owner <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUM <br /> -P�'tEPAIR• - :. --.�.. — S-t6te'Work"Done <br /> � //� <br /> DFgTRUCTIO'N 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 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 /> SIGNEhc�L TITLE ",I <br /> DRAW PLOT LAN ON REVERSE SIDE <br /> i FOR DEPARTMENT USE ONLY <br /> PHASE I C - DATE Z 7 <br /> APPLICATION ACCEPTED .BY <br /> ADDITIONAL COMMENTS: <br /> PIWBf-�I GROUT INSPECTION P SEI /FINAL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPLMN. <br /> R H 1426 5/731M <br />