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OAQUI KLOCA.L. HEALTH DISTRICT <br /> FOR.-OFFICE USE: ' 1 H z 1 on Ave. , .Stockton, Calif. <br /> e: (209) 466-6781 <br /> ATX 0 WELL CONSTRUCTION OR PUMP PERMIT Permit No. ] <br /> G-,. _2 THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 7� <br /> �'� (Complete In Triplicate} <br /> Application is 'he4e y?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/LOCATION,8013W1 VALPICO RD.-BETWEEN MAC ARTHUR & CENSUS TRACT <br /> C .- E WALNUT OI C <br /> Owner's Name ROBERT KELLOGG C/O CURRAN REAL ESNATE Phone <br /> Address = ..P.:O. BOX 414 City ' TRACY <br /> E Contractor's Name HENNINGS BROS. DRILLIN G CO. s INC'. License # 290813 Phone 545-1185 <br /> ND LEAVE. MODEST , <br /> F. _ . __ "^ a...'v e•�r-- <br /> TYPE-OF' WORK(Check) : <br /> NEW WELL�/X�—DEEPEN ,/—/ RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-7 <br /> Other — <br /> DISTANCE TO NEAREST: . .SEPTIC3TANK SEWER LINES PIT PRIVY. <br /> SEWAGEiDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE , . TYPE OF WELL CONSTRUCTION SPECIFICATIONS Q` <br /> t-_�— Industrial . '. - Cable Tool Dia, of Well Excavation n <br /> Domestic,/private 3 Drilled Dia. of Well Casing 6T1 laC <br /> Domestic/public Driven. Gauge of Casing 0 W 11 <br /> Irrigation Gravel Pack Depth of Grout Seal 150, C ; <br /> Cathodic Protection ` kX Rotary Type of Grout ��ntpraite <br /> Disposal Other Other Information <br /> Geophysical owner <br /> Surface Seal Installed By:drilleT � <br /> PUMP INSTALLATION: Contractor <br /> .Type of Pump H.P. <br /> PUMP REPLACEMENT /_7 State Work Done , <br /> PUMP :REPAIR <br /> - • �/ -� State Work -Done .. - <br /> .. „�. ...;.r�. <br /> _ yz�� <br /> DESTRUCTION OF WELL: .,!L Well Diameter I <br /> 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 -FOR A-GROUT INSPECTION <br /> PRIOR TO R � ING AND FINAL INSPECTION. <br /> SIGNED r TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEI�ARTMENT USE ONLY <br /> PHASE T <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE I/FINAL .INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> w � <br /> E H 1426 Rev. 1-74 .X.(77 . yes <br />