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+ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1-FOR -OFFICE USE: <br /> 1601. E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.7,'r � <br /> THIS. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . .Date Issued <br /> A (.Complete In. Triplicate) <br /> pplication 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/LO ATION.. - <br /> ., (F!SUS TRACT ' <br /> Owner's Name r,W' t•(/ `4"' east . s�d e <br /> Phone 6 -.8311 <br /> Address 1820 Beyer ' Lane' <br /> City Stockton <br /> Contractor's Name Hennings B 'os. �� <br /> Drilling Co. Inc. License # 290813 Phone 545-1 185.. ` <br /> 1�25 Peland ale Ave, IYMode s to <br /> _ t <br />( TYPE OF WORK (Check) : NEW WELL DEEPEN / / RECONDITION / / DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR,. <br /> -/�/ /;/ PUMP REPLACEMENT /� .. <br /> ^.-• �- ---�--- the r _ _,�� _ <br /> DISTANCE TO NEAREST: SEPTIC,TANK 1-0.0 S.EWER_LINES . PIT",PRIVY <br /> SEWAGE DISPOSAL FIELD X1.001-._CESSPOOL/SEEPAGE PIT OTHER -30t FROM , � <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL R OA Dom, <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial � <br /> Domestic Cable Tool, Dia. of Well Excavation <br /> a �? <br /> x '` <br /> /private Drilled Dia. of Well Casin n . <br /> Domestic/public' Driven g 3)]astin <br /> Gauge of Casing , 6 <br /> Irrigation / X Gravel Pack Depth of Grout Seal _50, <br /> Cathodic Protection X Rotary Type of Grout <br /> Bentonite <br /> Disposal Other Other Information <br /> Geophysical Slab--- Owner , <br /> Surface Seal Installed B' : i . driller <br /> PUMP INSTALLATION: -Contractor <br /> r � <br /> Type of Pump ' <br /> /H:P. <br /> PUMP REPLACEMENT.:, / /' State Work Done <br /> PUMP REPAIR: rr. r <br /> State Work Done <br /> DESTRUCTION OF:WELL': Well Diameter <br /> '- I Describe Material and Procedure Approximate Depth , <br /> I hereby agreetocomply with all laws and regulations of the San Joaquin Local Health District <br />.and_.the.-State-.of,Califo-r-nia 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 6�% e <br /> WELL DRILLERS REPORT of the well and notify them before putting. the well in use. . The above s <br /> information is true to the best ofmy knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED HENNINGS BROS . DRILLING CO. INC . By TITLE' € .''(DRAW PLOT PLAN-ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I - <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: <br /> A DATE 7 � <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE ( - <br /> E H 1426 Rev. . l-74 / 67.7 2M <br />