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F <br /> VX SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORrOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> I Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. � <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made I the San Joaquin local Health District for a permit to construct <br /> and/or install the work het{e'in 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 /> JOB ADDRESS/LOCATIONIMI ROTIT11CENSUS TRACT <br /> Owner's Name DEV T,OPMFNT Phone <br /> Address 51 1 <br /> _ _. City MANTECA <br /> Contractor's Name HENNINGS 60S. DRILLING CO. INC. License # 2 081 Phone 522-10al <br /> 2500 WRUMBLE MODEST O <br /> TYPE OF WORK (Check): NEW WELL /XT DEEPEN./? RECONDITION /-7 DESTRUCTION f7 <br /> PUPS INSTALLATION J PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other] /-7 <br /> DISTANCE TO NEAREST: SEPTICI' TANK SEWER LINES PIT PRIVY <br /> X SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER CT4 <br />` PROPERTY LINE -- PRIVATE DOMESTIC WELL '. PUBLIC DOMESTIC WELL W <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS O <br /> Industrial i Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing �WJt <br /> Domestic/public , Driven Gauge of Casing <br /> Irrigation ! X Gravel Pack Depth of Grout Seal O <br /> Cathodic Protection ^I Rotary Type of Grout <br /> Disposal i� Other Other Information <br /> Geophysical. Surface Seal Installed BY: CE <br /> 4 PUMP INSTALLATION: I <br /> Contractor <br /> Type of Pump H.P. <br /> is <br /> PUMP REPLACEMENT: / IT State Work Done <br /> PUI�:-REPAIR• /-7-5r.-ace. Work-Done <br /> ES, <br /> TRUCTTON 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 belie£. I WILL CALL FOR A GROUT IMSPECTION14 <br /> PRIOR TO GROUTING AND A ININ PECTION. <br /> SIGNED j <br /> _ 6, ITLE <br /> r (D LOT ON REV E SIDE <br /> FOR DEPARTMENT U ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 7S <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSTECTION P S FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> iA E H 1426 Rev. 1-74 1-74 2M <br />