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4 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> t'0F.­6.1 FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.17G/== �(l) <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7th <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 dr�d / � -�-�- CENSUS TRACT <br /> -C --� C� <br /> Owner's Name .J Phone <br /> Address 2 to L 'de ��'••�� City <br /> HENNINGS BROS. DRILLING CO., INC. <br /> Contractor's Name License # Phone ea.2:_SZ 4/3 <br /> 2500 W. RUMBLE ROAD <br /> LIF. LICENSE 116322 <br /> TYPE OF WORK (Check): NEW WELL XDEEPEN RECONDITION f_1 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION1 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> ✓`Domestic/private L--Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other L—Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP UPAIR: /7 State Work Done <br /> ,DFgTRUCTION 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. r <br /> SIGNEDTy4 <br /> (DRAW LOT PLAN ON REVERSE IDE <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL CO. S: <br /> P S Ii NSPECT P S I FINAL INSPECTIO <br /> INSPECTION BY ATE ___ liq INSPECTION BY DATE <br /> CALL FOR A UUT INSPECTION PRIOR TO GROUTING AND FINAL INSP ON. <br /> E Ii 1426 5/731M <br />