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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 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 Issued1 ' <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 ARBOR DR.-•600' EAST OF HOLLY DR.-NORTH SIDE CENSUS TRACT <br /> Owner's Name HOLLY SUGAR CORP. Phone 835-3210 <br /> Address 20500HOLLY DR. City TRACY <br /> Contractor's Name HENNINGS BROS. DRILLING CO. INC. License # 2_90813 Phone 545-1185 <br /> 3 52 PELANDALE AVE. , MOD.,C . 9a� <br /> TYPE OF WORK (Check) : NEW WELL /X/ DEEPEN/ / RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK NONE SEWER XINESPIT PRIVY <br /> SEWAGE DISPOSAL FIELD N CE SP OL/ EEPAGE PIT _ OTHER WELL--3 00' <br /> PROPERTY LINE - PRIVATE D STI EL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL i C STRUCTION SPECIFICATIONS <br /> _X Industrial Cable Tool ' D` 1 Excavation 18" <br /> Domestic/private Drilled a ell Casing 10"' <br /> NOXE <br /> Domestic/public Driven a f Casing /16 GA <br /> Irrigation X vel Pace D pt of Grout Seal 50, <br /> Cathodic Protection X [Rotary ype of Grout Cement <br /> Disposal titherOther Information SLAB-BY OWNER <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 /> 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`° <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 HENNINGS BROS. DRILLING M9ING. BY _ TITLE SEC* <br /> (DRAW PLOT PLAN ON REVERSE SIDE)( <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY yyi1 ��`"' DATE 'j' <br /> ADDITIONAL COMMENTS. a L <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. - 1-74 <br />