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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORjOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7Sr-3r�6 t�1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Zj3-7S_ <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 + CENSUS TRACT <br /> Owner's Name Phone a-�;=�Q e-a <br /> Addressoo?IF- <br /> City27 ......� <br /> Contractor's Name Hennings Bros Drilliri Co. I e . License # 29081 Phone 522-10_11. <br /> 2 00 W. Rumble Rd. ModeSto <br /> TYPE OF WORK (Check): NEW WELLDEEPEN /_7 <br /> /7 RECONDITION /_7 DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR /7 PUMP REPLACEMENT /7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE AOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation - <br /> A--gomestic/private Drilled Dia. of Well Casing - <br /> � ,� Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal s <br /> Cathodic Protection &---Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP :REPAIR: /? State Work Done <br /> e <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-best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNEDnri ] iingTITLE / 2 0, Sec. <br /> DRAW PLOT PLAN ONREVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PW E I GROUT INSPECTION P I FINAL IN <br /> INSPECTION BY DATE INSPECTION BY DATE__3 �� <br /> } E H 1426 Rev. 1-74 <br /> 1_7, ,,,, <br />