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w l f4 CAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFfi •OFFICE .USE: `` 1601' E. Hazelton Ave. , Stockton, Calif <br /> Telephone: (209) 466-6781 ! <br /> :. APPLICATION FOR WELL CONSTRUCTION OR PUMP P. IT', Permit No. 7,7-1.5,5 <br /> U �. <br /> 41) <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 , dtegulati ns of the San Jquip Local Health District. <br /> JOB ADDRESS/LOCATION �� Ge r G!S 7—I` 7 &7 CENSUS TRACT <br /> Owner's Name Al Brocchini Farms Phone -599-k22-9 <br /> Address 27011 . S Austin Rd. City RiI)nn <br /> Contractor's Name Hennings Bros. Drilling Co. Inc License # 2 081 Phone 522-1 0 1 <br /> =00 W. Rumble Rd., Mod. i <br /> TYPE OF WORK (Check) : NEW WELL/17 DEEPEN / / RECONDITION / / DESTRUCTION /^T <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT /—T <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK I M ( SEWER LINES ( A4 ( - PIT PRIVY <br /> SEWAGE DISPO FIELDZ�� CESSPOOL/SEEPAGE PIT �,a OTHER <br /> AL <br /> PROPERTY LINE — PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS v <br /> Industrial Cable Tool Dia. of Well Excavation P41t <br /> Domestic/private Drilled Dia. of Well Casing 16" <br /> Domestic/public Driven Gauge of Casing 4rA <br /> Irrigation X Gravel Pack Depth of Grout Seal .. <br /> Cathodic Protection X Rotary Type of Grout <br /> Disposal Other Other Information e� ., -bX owner <br /> Geophysical Surface Seal Installed Bys» <br /> PUMP INSTALLATION: Contractor S7lC4 <br /> Type of Pump 16C H.P. oSF. <br /> ff <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 thewellin 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 N(;eAND A FINA& INSP CTION. <br /> TITLE , <br /> SIGNED <br /> DWAW MT PLAN ON REMSE SIDE) ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II OUT INSPECTION PHASE I/FI INSPECTION <br /> INSPECTION BY DATE INSPECTION BY IDATE <br /> 3/76 2M <br /> E H 1426 Rev. 1-74 <br />