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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7Zy <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued J�/1 <br /> (Complete In Triplicate) /�us,�� Per"1 7g"-?-f 5' , <br /> Application is $ereby 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 NtiW, COMER OF AUSTIN RD. & SEDAN AVE, CENSUS TRACT <br /> Owner's Name BIANCHI ENTERPRISES r L Phone 821-6423 <br /> Address P.O. BOX 105 5vr'. r3�ti �3,a, i �� -easa City _ NTECA <br /> Contractor's Name HENNING:S BROS. DRILLING CO. o INC. —.License # 290813 Phone 545-1185 <br /> �52 5 PELANDALE AVE. , MOD. <br /> TYPE OF WORK (Check) : NEW WELL _� DEEPEN /_/ RECONDITION /_/ DESTRUCTION /- <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC TANKNONE SEWER LINES NONE PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER NONE '? <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 2611 <br /> Domestic/private Drilled Dia. of Well Casing 16 <br /> Domestic/public Driven Gauge of Casing dGA,_ <br /> X Irrigation X Gravel Pack Depth of Grout Seal <br /> Cathodic Protection X Rotary Type of Grout .. <br /> Disposal Other Other Information SLAB*BY OWNER <br /> Geophysical Surface Seal Installed By: A <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 istrict <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 TITLE t_ra, R <br /> (DRAW PLOT PLAN QrN REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY r DATE /04Z? 2 <br /> ADDITIONAL COMMENTS: <br /> PHASE II OUT IlTSPECTION PHAS 1 FINAL INSPECT ry <br /> INSPECTION BY DATE INSPECTION BY DATE D7d <br /> 2 <br /> rZ7 2M <br /> E H 1426 6 Rev. 1-74 <br />