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SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> Ftp OFFICE USE: W(d 1601 E. Hazelton Ave. , .Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 <br /> � THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> r� r (Complete In Triplicate) <br /> Application is dere made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the w k herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 2 and the Rules and Regulations of the San Joaquin Local Health Dist#ct. <br /> JOB ADDRESS/LOCATIO �� <br /> AUSTIN RD.-600t NORTH OF LOUISE AVH;qSUS TRACT <br /> EAST SIDE <br /> Owner's Name RAYMUS REALTY Phone 823-3148' <br /> .tet <br /> Address 544 ;. YOSEMITE AVE. City MANTECA <br /> Contractor's Name HENNINGS BROS. DRILLING CO. INC. License # 290813 Phone 545-1185 <br /> 3575 , , <br /> TYPE OF WORK (Check): NEW WELL / 7 DEEPEN%% RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR 17 PUMP REPLACEMENT /-7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK 1W SEWER LINES /0,01 PIT PRIVY -- <br /> SEWAGE DISPOSAL FIELD — CESSPOOL/SEEPAGE PIT— OTHER 1 � <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 61, <br /> Domestic/public Driven Gauge of Casing 160 W41j <br /> Irrigation Gravel Pack Depth of Grout Seal 5Ot - <br /> Cathodic Protection X Rotary Type of Grout Bentonite <br /> O <br /> Disposal Other Other Information � .ab_Z,y p3pMer <br /> Geophysical Surface Seal Installed BY: drf 3.a� ._.. <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H. <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 HENNINGS BROS,DRILLING CO. .INC. . BY TITLE <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPART NT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONALCOMMENTS: <br /> PHASEI GROU INSPECTION PHASE I FIN INSPECTION <br /> INSPECTION BY4ZADATE - INSPECTION BY DAT / <br /> 56. ., .: <br /> E H 1426 Rev. 1-74 1177 2M <br />