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u� SAN JOAi N LOCAL HEALTH DISTRICT <br /> F0' OFFICE USE: 1601 E. HaEW Ave. , Stockton, Calif. <br /> ` Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 -sS3eJ <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 Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> Scott <br /> JOB ADDRESS/LOCATION 2129 Albert Ct. & CENSUS TRACT <br /> Owner's Name Don Coses Contractor Phone AT5-0966 <br /> Address P.O. Box 326 City `i'rgcy <br /> Contractor's Name Hennings Bros. Drilling Co. ;Ino. License # 29Q Phone 5p2_jf)�1 <br /> 2500 W. Rumble Rd.. Mod. i <br /> TYPE OF WORK (Check) : NEW WELL /X DEEPEN—RECONDITION /_/ DESTRUCTION /_7 <br /> AL <br /> PUMP INSTLATION/—/ PUMP REPAIR/ / PUMP REPLACEMENT /_ <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 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 11 " <br /> X Domestic/private Drilled Dia. of Well Casing 6T'--Plastic <br /> Domestic/public Driven Gauge of Casing 160 wall <br /> Irrigation Gravel Pack Depth of Grout Seal 0t <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 /> SIGNED BENNTNGS BROS. DRILLING 02INC. BY TITLE Q E <br /> !7,ZDRAW PLOT.PLAN ON RE RSE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY �Ct_- DATE /2— 7 INSPECTION BY _ DATF�/'�• 1.-�Z,L' <br /> a <br /> E H 1426 Rev. 1-74 <br /> 3/76 2M <br />