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„� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFirOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Cali <br /> Telephone: (209) 466-6781 fJ <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PE Permit No. 7 47,9&) <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 Ordinan No. 1862 and the Rules and Regulations of the San Joaquin Local Health District, <br /> ,JOB ADDRESS �ON 0 �-�-•- <br /> I CENSUS TRACT <br /> Owner's Name Phone a y <br /> Address City <br /> Contractor's Name HENNINGS BROS. DRI TNG CO., INC. License # 290813 Phone 522•-103 .\. <br /> W. RUMBLE RD. MOD � . <br /> TYPE OF WORK (Check): NEW WELL DEEPEN/7 RECONDITION /7 DESTRUCTION j <br /> PUMP INST KATION /-7 PUMP REPAIR /7 PUMP REPLACEMENT /7 <br /> Other Z 7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 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 r <br /> 1---Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection ems-- Rotary Type of-'Grout' <br /> Disposal . _. Other Other Information <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. A` <br /> PUMP REPLACEMENT: / / State Work Done t <br /> ..PUMP-'REPAIR-;--- = - ./7 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 FORA GROUT INSPECTION <br /> PRIOR TO GROUTI G AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE I <br /> FOR DEPARTMENT' USE ONLY <br /> � . . <br /> APPLICATION ACCEPTED BY DATg53 �-�y <br /> 46 <br /> ADDITIONAL COMMENTS: <br /> ” PISS ""I GOUT INSPECTION P S I FINAL INSPECTIQN <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1-74 1-74 2M <br />