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i Y <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT , <br /> FOR OFFICE- USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 ! <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. , _12l#lr/ � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued ��•1Z 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 instal:l -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 Sarit0-i eve..€ CENSUS TRACT <br /> Owner's Name Charles Travaille Phone 599-4497 <br /> Address 12136 E. Graves City Manteca <br /> Contractor's Name Hennnings Bros. Drilling Co. , Inc. License #116322 Phone 522_56 -3 <br /> Rumble Ra. Modesto, a . 95350 <br /> TYPT; OF__WORK (Check)_NEW4WE_LL _L =�DEEP.EN�_/a/�RECO.I3D-IlION_/-T Di5sn 3_CT:ION�/����_ <br /> PUMP.- INSTALLATION / f PUMP REPAIR / / PUMP REPLACEMENT /_ <br /> Other / % — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE .DI.SPOSAL FIELD - CESSPOOL/SEEPAGE PIT ^� .. OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 241t <br /> Domestic/,private Drilled Dia. of Well Casing 16r� <br /> Domestic/public Driven-Irrigation X Gravel Pack Depgh of Grout e of gSeal <br /> .....____ 1,/�-+•rr,_—� <br /> Other X 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 -= --R APPraximate epth -: = - <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 /> Hennings ;Bros . Drill' Co. , Inc. <br /> SIGNED __. _ _ <br /> (DRAW PLOT- PLAN ON REVERSE SIRE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I _ _.. . ..E <br /> APPLICATION ACCEPTED BYDATE X2- Z 7�- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P I/ .NAL INSPECTION <br /> INSPECTION BY DATE INSPECT IO Y DATE 1 -`'- <br /> CALL FOR A-GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 7/72 1M <br />