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i _ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOr.:OF1 ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. 1 <br /> Telephone: (209) 466--6781 ^� <br /> ' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.T 3�c Ll� <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 Joagt <br /> r County Ordinance: No. 1862 and the Rules and Re ulations of the San Joaquin-Local Health District. <br /> 1 86 SOUTH 1-�- <br /> JOB ADDRESS/LOCATION MILE NORTH OF CAF40LTON <br /> CENSUS TRACT <br /> Owner's Name BERT BALLATORE Phone 599-3476 <br /> 19988 SOUTH CAFOLTON <br /> Address City RIPON <br /> I` <br /> L Contractor's Name HENNINGS BROS. DRILLING CO-} INC, License #116322phone 522--5643 <br /> i 2 00 W. Rumble Rd. Moilesto, a R <br /> 't—TYPE OF WORK (Check): NEW WELL '±_/ DEEPEN /_/ RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT (7 <br /> Other -/ / — — <br /> DISTANCE TO NEARE�,T;� SEPTIC TANK /00 . SEWER LINES _2 S pIT PRIVY �0 <br /> /},�' SEWAGE DISPOSAL FIELD v CESSPOOL/SEEPAGE PIT r/ OTHER <br />+� } INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> LF Industrial "� Cable Tool Dia. of Well Excavation 101 <br /> . X Domestic/private Drilled Dia. of Well Casing fr <br /> Domestic/public Driven Gauge of Casing 1 <br /> Irrigation Gravel Pack Depth of Grout Seal 50t <br /> Other g_ Rotary Type of Grout Bentonite <br /> Other Other Information a y owner <br /> k <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br />¢ PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'tEPAIR: / / State Work Done f�, <br /> a —. ..._.._.. r <br /> i <br /> ,DFcTRItGTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and .Procedure <br /> I hereby agree 't� 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 onla, new well, I will furnish the San Joaquin Local Health District a ;. <br /> WEL•L,DRILLERS. REPORT of the well and notify them before putting the well in use. The above <br /> Mnforma i ,is true to the best of my knowledge and belief. <br /> SIGNED TITLE <br /> L LAN ON REVERSE SIDE) <br /> t OR DEPARTMENT USE ONLY I <br /> PHASE I <br /> APPLICATION ACCEPTED .BY DATE <br /> ADDITIONAL_ COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS II/FINAL INSPECTION <br /> ION BY <br /> INSPECTION. BY DATE INSPECTDATE .�- <br /> ,S <br /> CALL FORA GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. 2� <br /> B H 1426 ff /7-1 C <br />