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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. • i <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued-t—73 <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 TRA Y CENSUS TRACT <br /> TWO MILES <br /> Owner's Name FRANCIS BACCHETTI Phone 815_2106 <br /> Address 18700 BACCHETTI RD. City TRACY1 CAL <br /> Contractor's Name Hennings Bros. Drilling Co. 9 Inc. License # 116322 Phone 522-6 61+3 <br /> 2500 W. Rumble Rd-:--Modes o, Cal <br /> TYPE OF WORK (Check) : NEW WELL /f/ DEEPEN /_/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TAUNK—�-%f}` SEWER LINES PIT PRIVY <br /> XSEWAGE DISPi�.:>NL FIELD -f�-�- CESSPOOL/SEEPAGE PIT OTHER pop <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Q <br /> Industrial Cable Tool Dia, of Well Excavation bitQ <br /> X._ Domestic/private _ Drilled Dia. of Well Casing 12" <br /> Domestic/public Driven Gauge of Casing 12 GA A <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other y Rotary Type of Grout <br /> Other Other Information Slab: By Owner <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEME14T: / / 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. <br /> SIGNED TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY � DATE L/ y-2`? <br /> ADDITIONAL COMMENTS: j <br /> PHASE II GROUT INSPECTION `_= PHASE II FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY it DATE7-0 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPE ION. /Xj►, <br /> E H 1426 7/72 1M V4`� <br />