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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR7OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7f� � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued J 7� <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 /> JOB ADDRESS/LOCATION GO .:,�. rh._..� CENSUS TRACT <br /> Owner's Name DEL AU CH Phone <br /> Address 136 LINCOLN BLVD - ...___.. City TRACY <br /> Contractor's Name HENNINGS BROS. DRILLING CO. INC. License # 290813 Phone - 522-1031 <br /> 0 . <br /> TYPE OF WORK (Check): NEW WELL T DEEPEN/7 RECONDITION /7 DESTRUCTION /7 <br /> PUMP INSTALLATION L_7 REPAIR-/`7 PJMP REPLACEMENT 17 <br /> Other L7 . . . . . . <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY C►� <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' : d PUBLIC DOMESTIC WELL D <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 4 <br /> � ' Industrial Cable Tool Dia. of Well Excavation t! <br /> _X Domestics/private Drilled Dia. of Well Casing _ 6_5/8" <br /> Domestic/public _.__..�_ Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal $ <br /> Cathodic Protection X Rotary Type of Grout - RPritnni fi0 _- <br /> Disposal ..._.-� Other Other Information -" <br /> Geophysical Surface Seal Installed Bv: ..,,.•'drill er _....� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: . L/ State Work Done <br /> PUMP '.REPAIR: /7 State Work Done <br /> ES•'TRUCTION 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-bent-of- my-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNEDNG CO. INC. BY TITLE _, SEC. <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY C .. DATE ' ¢Z <br /> ADDITIONAL COMMENTS: . . .. <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY CDATE ITy INSPECTION BY DATE <br /> E H 1426 Rev. I-74 h/75 2M <br />