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SAN JOAQUIN LOCA %,�ALTH DISTRICT <br /> FOF..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 Joaaquin,Local Health District for a permit to construct <br /> and/or install the work herein described. . This application is made in compliance with Sen Joaquin <br /> County Ordinance No. 1862 and Pte�4ules and R gulations of the San Joaquin Local Health District. <br /> �F <br /> JOB ADDRESS/LOCATION MV, <br /> WXT <br /> Owner's Name Raymond L. Smith Phone $23-2280_ <br /> Address 328 Flores Ct: City Manteca, Cal. - <br /> Contractor's Name Hennings Bros . Drilling Co. ;, Inc . License #290$13 phone 522-1031 <br /> 7500 West um e . o e ,. . <br /> TYPE OF WORK (Check) : NEW WELL a DEEPEN -/_7 RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/_7 PUMP REPLACEMENT /7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK 100? SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD1001+ CESSPOOL/SEEPAGE PIT OTHER <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 ll'r <br /> Domestic/private XX Drilled Dia of Well Casing . - <br /> Domestic/public Driven = Gauge of Casing T 2 a <br /> Irrigation Graver""Pack Depfh'of Grout Seal - <br /> Cathodic Protection XX Rotary 1 ,Type of Grout , , Pentonite <br /> Disposal - Other Other Information Slab by owner <br /> Geophysical Surface Seal Installed By: Driller <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR. <br /> -- / / 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 INSP CTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. BY: �� <br /> SIGNED TIENNINGS BROS-. DRILLING CO. , INC * TITL � BMWECT IY <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE �Q y�- ] <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P I F INSPECTIO <br /> INSPECTION BY DATE 0-;y-7 S_ -INSPECTION DATE <br /> E._ E H 1426 ,Rev: 1-74 _. --�.._ <br /> 1x/75 2M <br />