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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FO OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone-.1' (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,;;- 3 S'Gbj <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issuedg 73 <br /> `t (Complete In Triplicate) <br /> Application its 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 off the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �°Cy -�- �jt ,�,r, f CENSUS TRACT <br /> Owner's Named Ems' e �y�ry,� Phone <br /> Address City <br /> HENNINGS, BR RILLIG/ I C. License >'{ Phone �(� � <br /> Contractor's Name 1 Gtt , <br /> 2500 W. R MBL <br /> MODESTO, CALIF. dLlCSE 116322TYPE OF WORK (Check): NEW WELLDEEPEN /� RECONDITION /� DESTRUCTION /-7 <br /> PUMP INSTTION / / PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private //Drilled Dia. of Well Casing � <br /> Domestic/public Driven Gauge of Casing /� ;�-E4- <br /> Irrigation Gravel Pack Depth of Grout Seal _ <br /> Other ,j.-Rotary Type of Grout . <br /> Other Other Information <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 JTITLE <br /> (D T PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY la 2z DATE 7 3/�;,j <br /> ADDITIONAL COMMENTS: <br /> PHASE II ROUT INSPECTION PHASE, III FINAL INSPECTION <br /> INSPECTION BY F ATE k-a0. INSPECTION BY DATE q-/3-73 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M C <br />