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f SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> For..OF ICE USE: 71601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br />{ (Complete Injriplicate) <br /> Application is hereby made to the San Joaquin. Local Heal .h, 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. 1562 and the Rules and Regulations oaf the San Joa uin Local Health District. <br /> �3 c,-n cs� _S , c.t-t r�.i..'r�i� � • #' �'•"' �,s3-- Z��/D1 JOB ADDRESS/LOCATION GHRISM.AN RD.- 1MI. SOUTH OF LINNEIEAST alpF. CENSUS TRACT , <br /> Owner's name TTM RgSKFTTE _ Phone <br /> Address 121 -W. LINNE RD. City ' <br /> TR Cy <br />�- Con.tractor's-Name--IiENNINGS_.BROS. DRILLING_C0. INC. License # Phone <br /> 2500 W. RUMBLE RD. MODEM �. -11�3s y-_ --?�-- ,, <br /> TYPE OF WORK (Check) : NEW WELL '/X-/ DEEPEN '/—/ RECONDITION / / DESTRUCTION /_" <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES --- PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT . -- OTHER X <br /> • E <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 1211 <br /> X Domestic/private Drilled Dia. of Well Casing - 8=5- u, <br /> Domestic/public Driven Gauge of Casing 10$ GA <br /> r Irrigation Gravel Pack Depth of Grout Seal1 ._z4 i1 � <br /> Other X Rotary Type of Grout Bent .-j <br /> Other .QI}�c.�,_..,.. <br /> �4 <br /> Other Information S lab- by QkMer <br /> PUMP -INSTALLATION: Contractor . <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'tEPAIR: <br /> State Work Done <br /> .DFgTRUCTION 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 /> SIGNED f <br /> TITLE <br /> (D OT PLAN ON REVERSE SIDE) <br /> R.DEPARTMENT USE ONLY <br /> PHASE I A .. . <br /> APPLICATION ACCEPTE ' <br /> ADDITIONAL COe91, <br /> DATE /(-7 3 <br /> P ROUT INSPECTION P I/FI INSPECTION <br /> INSPECT DATE _ INSPECTI <br /> DATE <br /> . CALL FOR A-GROUT INSPECTION PRIOR TO G OUTING AND FINAL INSPECTION. <br /> E H_ 1426 " . C /7-1 <br />