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C_-) SAN JOAQUIN LOML HEALTH DISTRICT \. <br /> FOR OFFICE US 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> AP -LICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�--5-3- "j <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued g Zp-�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 /> Cose <br /> JOB ADDRESS/LOCATION 211+4 Albert Ct. & Hwy 13 CENSUS TRACT <br /> Owner's Name Don Cote, Contractor Phone 83,5-0966 <br /> Address P.O. Box 326 _ City Tra ey <br /> Contractor's Name Henning imngq. nri l l i ng CO. ,,Ine. License # 290813 Phone 522-1031 <br /> 2500 W. Rumble Rd. . Mod. <br /> i <br /> TYPE OF WORK (Check) : NEW WELL /X/ DEEPEN/_/ RECONDITION f-1 DESTRUCTION /-7 <br /> PUMP INSTALLATION/—/ PUMP REPAIR/ / PUMP REPLACEMENT /-7 <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 ti <br /> Domestic/private Drilled Dia. of Well Casing 6" pla stiE <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 InformationSlab-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 P <br /> e <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 HENNING2 BROS. DRILLING CO INC. BY TITLE SEC. <br /> DRAW -PLOT PLAN ON RE RSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY � DATE -- <br /> ADDITIONAL COMMENTS: <br /> P II G OUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY ATE��-� _` INSPECTION BY Age4 DAT .-,.22- ; <br /> E H 1426 Rev. 1-74 376 2M <br />