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9� /`, SAN JOAQUINJL,CCA.e HEALTH DISTRICT <br /> ME OFFICE USE: t 1601 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 /O- G <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 /> Olsen <br /> JOB ADDRESS/LOCATION 2101 Albert Ct.4 Hwy 33 CENSUS TRACT <br /> Owner's Name Don COse Phone 835-0966 <br /> Address P.O. Box 326 City Tracy <br /> Contractor's Name Hennings Bros, Drilling Co. Inc. License # 290813 Phone 522-0131 <br /> 2500 Wl Rumble Rd. , MR, . i <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN /7 RECONDITION /—T DESTRUCTION /_7 <br /> PUMP INSTLATION REPAIR/ / PUMP REPLACEMENT /� <br /> AL <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL p <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS \^J <br /> Industrial Cable Tool Dia. of Well Excavation 11 °' <br /> X Domestic/private Drilled Dia. of Well Casing 6" 7plastic <br /> Domestic/public Driven Gauge of Casing _ 160 wall <br /> Irrigation Gravel Pack Depth of Grout Seal 50t <br /> Cathodic Protection X Rotary Type of Grout Bentonite <br /> Disposal Other Other Information Slab-by owner <br /> Geophysical Surface Seal Installed By: driller <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION 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 /> S <br /> SIGNED NNINGS 'S. INC. BY TITLE C• <br /> DRAW 'I PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I c <br /> APPLICATION ACCEPTED BY DATE ( � <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P E III FINAL INSPECTION <br /> INSPECTION BY DATE -7-7- 7,4 _ INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 3/76 2M <br /> u <br />