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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. <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 Loc 1 Health District. <br /> o�TG <br /> JOB ADDRESS/LOCATION d - , !/S !N r CENSUS TRACT <br /> Owner's Name Robert Bordenave Phone 883-4104 <br /> Address 305 Mylnar avenue City Manteca <br /> Contractor's Name Hennings Bros. DJ'illing Co. , Inc. License # 116322 Phone 522-5643 <br /> TYPE OF WORK (Check) : NEW WELL /W DEEPEN /-7 RECONDITION /- DESTRUCTION / <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / J <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY r , <br /> X SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 6- <br /> Industrial Cable Tool Dia. of Well Excavation lU S <br /> X Domestic/private Drilled Dia. of Well Casing -- <br /> Domestic/public Driven Gauge of Casing 12 GA L <br /> Irrigation Gravel Pack Depth of Grout Seal �sY> <br /> Other F Rotary Type of Grout <br /> Other Other Information <br /> 00, <br /> PUMP INSTALLATION: Contractor ` <br /> Type of Pump H.P. J <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: /% State Work -Done <br />,pESTRUCTION 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. <br /> BE INGS BRAS. DRILLING CO. , INC. <br /> SIGNED � 't / TITLE BOOKKEEPER <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 1-2 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY 4jdL ,. ._. DATE ,!2 ^" <br /> CALL FOR A GRO`I IN idffbN PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M v <br />