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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. -n- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date 'Issued a 2 <br /> r (Complete In Triplicate) <br /> i' Application is Aereby 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 /> Countyy00 dinnance. No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS <br /> /LOCATIONSEDAN AVE..,.-A-MI T OF <br /> SUS TRACT <br /> Owner's Name J.E . POTTFR <br /> Phone - _ _6 <br /> Address Address f 93b2 S. AUSTIN RD. <br /> City' MANIRC <br />` Contractor's Name . HENNINGS BROS. DRILLING 0.6. INC License # Phone <br /> VE. MOD TO <br /> TYPE OF WORK (Check): NEW WELL <br /> IK7 DEEPEN /_/ RECONDITION /-J DESTRUCTION /_7 . <br /> PUMP INSTALLATION PUMP REPAIR / / PUMP REPLACEMENT /_7 � '' <br /> Other <br /> n � 4 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES SE . PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHERLt1E�1__ <br /> �• PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELT. <br /> INTENDED USEf- TYPE OF WELL ,CONSTRUCTION SPEGIFICATIUNS <br /> Industrial Cable Tool Dia. of Well Excavation 11 <br /> Domestic/private Drilled Dia. of Well Casing sa <br /> Irrigation <br /> Domestic/public Driven Gauge of Casing -- 160 wall <br /> Irrigation Gravel Pack Depth of Grout Seal r <br /> Cathodic Protection X _ Rotary Type of Grout _ <br /> Disposal `5' Other BehtLni <br /> Other Information Xuab-h� n rnp?% <br /> Geophysical -Surface Seal installed By• <br /> PUMP INSTALLATION: y <br /> Contractor - <br /> Type of Pump i <br /> ". H.P. . . . , <br /> PUMP REPLACEMENT: / / State. Work Done_ <br /> , . , <br /> PUMP 'REPAIR: <br /> —0—state Work Done <br /> U Gt�F L C� ;�rp l�i�A��Gl jk e P Q 0 riP U ni 0 ✓ <br /> there <br /> N OF WELL: ell Diameter yy <br /> �— /__,_Ap ximate.De th <br /> Des_vibe Material' and Procedure T <br /> o comply with all laws and regulations of the San Joaquin Local a <br /> H r 2r/s <br /> t <br /> and the State of California pertaining to or regulating well "construction. Within FIFTEETDAYS <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 />'RIOR TO GROUTING AND .A FINAL INSPECTION. <br /> SIGNED INC TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) . <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE <br /> PHASE II GROUT INSPECTION PHAS III/FINAL INSPECTION <br /> INSPECTION BY DATE <br /> �Spt <br /> CTION BY DATE <br /> 604 <br /> E H 142£, ne.. � �i. hr.rne. .i.�� - _ / � e <br />