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�l SAN JOAQUIN LOCAL-HEALTH DISTRICT <br /> FW,,OFFICE USE: I v 1601 E.'_Hazelton Ave. , Stockton, Calif. <br /> V Telephone: ' (209) 466-6781 . <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit .No. X7,3 4J <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 appi.ication is made in compliance with San Joaquin; <br /> County Ordinance No: 1862 andithe Rules and Regulations of the San'Joaquin Loc.a3. health District. <br /> JOB ADDRESS/LOCATION 1 5655 E'. HW �20---ro ETH c NsuS TRACT F <br /> RIPON RD. , NORTH SIDE <br /> Owner's Name A 'MATTA.S. Phone .20 <br /> Address 6 E . 2• city. , <br /> t License � Phone ,5�?-1O' <br /> Contractors Name HE I G , BRO . D G L3 <br /> 2 00 W. RUMBLE RD MODESTO <br /> TYPE OF WORK (Check): NEW WELL.'jF DEEPEN '/7 RECONDITION f_7 DESTRUCTION /7PUMP INSTALLATION f PUMP REPAIR/? PUMP REPLACEMENT /? ; <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK ,4 SEWER LINESPIT PRIVY �D [� <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHHR I00 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS OVI <br /> Industrial •1 Cable Tool Dia. of Well Excavation _1 <br /> X_ Domestic/pfivate . i Drilled Dia, of Well Casing 6_- e81, <br /> —Domestic/public.' Driven = Gauge of-Casing- - - <br /> Irrigation ► 4 Gravel Pack Depth of Grout Seal 1 <br /> Cathodic Protection ' X - Rotary Type of Grout <br /> F <br /> .S TDiepDeal Other Other Information n: np <br /> —Geophysical Surface Seal Installed 'B i . <br /> i <br /> PUMP INSTALLATION: Contractor <br /> Type .of Pump H.P. <br /> t <br /> PUMP REPLACEMENT %/ State Work Done <br /> PUMP ,REPAIR: /_ :State Work Done �V <br /> f DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> t 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 €urnish 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 /> k information is true to-the,best-of my,knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED HENNINGS BROS. DRIEETNG 5INC. BY TITLE SEC'. <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> iPHASE I DATE <br /> PLICATION ACCEPTED BY <br /> I ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II AL FI INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE 71 <br /> .oi.�� <br /> 4 2M <br /> E R 1426 gav_ 1-74 n. <br />