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Y <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT c <br /> FOR CF'FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.-7-f— 38�1c1 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 3-7� <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 with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health'District. <br /> JOB ADDRESS/LOCATION 11821 W. Vl__jPico CENSUS TRACT �=5� <br /> Owner's Name Fred Peters Phone 835-2844 <br /> Address 225 East Grant Line Rd. City Tracy <br /> Contractor's NameHennings Bros. Drilling Co. � Inc. License # 116322 <br /> Phone 522-•56+3- <br /> 0 W. Rumble Rd. Modes o Gais50 <br /> TYPE OF WORK (Check) : NEW WELL /X-/ DEEPEN /_7 RECONDITION /_/ DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK 6 9F SEWER �INES PIT PRIVY <br /> SEWAGE DISPOSE FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation lly <br /> X . Domestic/private Drilled Dia. of Well Casing H-1 <br /> -Domestic/public Driven Gauge of Casing 12 Ga <br /> Irrigation Gravel Pack Depth of Grout Seal 50t <br /> Other y__ Rotary Type of Grout _ Bentonit <br /> Other Other Information OW,-Iep <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / 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 _ �4 , TITLE <br /> PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> ,PHASE I C� <br /> APPLICATION ACCEPTED BY C DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIONP E' 11 1 INAL INSPECTION <br /> INSPECTION BY DATE INSPECTIODATE v <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />