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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORtOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> *a Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.�4/� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7V <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to Constxuct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and-thqL Rules and Regulations of th2, San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> v Phone tit <br /> Owner's Name ,'� <br /> Address <br /> • 29®81.3 <br /> Contractor's Name KENNINGS BBQ DRILLING CO., INC. License Phone 522=1031„O 1 <br /> 2500 W. RUMBLE RD. �MODEST02 CAL. 95350 <br /> TYPE OF WORK (Check): NEW WELL DEEPEN /? RECONDITION DESTRUCTION f7 <br /> PUMP INSTALLATION L-7 PUMP REPAIR /7 PUMP REPLACEMENT /7 <br /> Other / 7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER V <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 Nrs <br /> Domestic/private i--Drilled Dia. of Well Casing <br /> , -Tomestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 4--Rotary Type of Grout <br /> Disposal Other Other Information <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: ,(_7 State Work Done <br /> pES•TRUCTION 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 thewell 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 -•M d TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> Al- <br /> PHASE I ATE <br /> APPLICATION ACCEPTED BY DATE <br /> --- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAA 1117FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 2 <br /> E H 1426 Rev. 1-74 1-74 2M <br />