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SAN JOAQUIN LOCAL_ HEALTH DISTRICT l ✓C� I <br /> F401`- OFFICE USE: 1601 E. Hazelton Ave. , ,Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 77-1-3-3141- <br /> THIS <br /> 7/.3,3jcTHIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued /0 oJ/-/7- i <br /> (Complete In Triplicate) <br /> Application is Aerebymad.e.,to the San Joaquin Local Health District for a permit to construct' ; <br /> and/or install the work herein described.'-.ihis application is made in compliance with San Joaquin, <br /> County Ordinance No. 1862 and the Rules aV Regulations of the San Joaquin Local Health District. , <br /> gig <br /> ' <br /> JOB ADDRESS/LOCATIONCAM ELL AVS tr-a,QU T OF M.AHON AVE . EAST CENSUS TRACT <br /> SIDE <br /> Owner's Name CHUCK STONE Phone 5�8-•0969` <br /> i <br /> Address P:O. Box 4714 City MODESTO <br /> Contractor's Name HENNINGS BROS. DRILLIN..G CO`. INC. .License # 290813 Phone 545-1185 <br /> 3 52 5 PE UA—ND-=AVE e MOD a <br /> i' <br /> TYPE OF WORK (Check) : NEW WELL /$/ DEEPEN /_/ RECONDITION /—/ DESTRUCTION ,1.7 . . . <br /> PUMP INSTALLATION / / . PUMP"REPAIR '-/ /, -PUMP-REPLACEMENT /7 <br /> 1A <br /> Otlf8r -A1 <br /> DISTANCE TO NEAREST: SEPTIC TANK /a// SEWER LINES PIT PRIVY offvwty <br /> SEWAGE DISPOSAL -FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE. - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE <br /> -TYPE OF` WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ,Jf. Cable ,Tool Dia. of Well Excavation . <br /> X Domestic/private Drilled Dia:, of`Well Casing ; 10tr <br /> Domestic/public Driven Gauge-of--Casing erofCasin Q ' <br /> /P "- <br /> 8 g ° '.3,/1 E3CiA - <br /> X Irrigation _'Gravel Pack Depth of-Grout Seal _ 50t <br /> Cathodic Protection X Rotary 'Type of Grout CEMENT <br /> Disposal Other _ *, r ' Other Information S ,AR=F3Y CWNFR <br /> Geophysical Surface Seal Installed By: UTTIER <br /> F <br /> PUMP INSTALLATION: ti Contractor R <br /> Type-of(Pump _ . <br /> H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP­REPAIR / / State Work Done <br /> DESTRUCTION OF WELL; Well Diameter r Approximate Depth <br /> Describe Material and Procedure <br /> ' I <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well "construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a .�, <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED HEINNINGS BROS. BY TITLE IR"j,, — <br /> ( RAW P Og PLAN ON REVERSE SIDE) <br /> FOR 'DEPARTMENT USE ONLY <br /> PHASE 1 DATE /e:�W`7Z <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHA$E /FINAL INSPECTION <br /> INSPECTION BY DATE ► 1 - 3-"7 7 INSPECTION BY ATE 11 _? <br /> ,,�,q 10�-r U PZd�''�� r' w off- ,, / 1177 <br /> W u I A 9A n-.. 1_71. C4 ,.'- 11 177 t- D. dc� ` <br />