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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOB OFFICE USE: 1.601 E. Hazelton"A,e. , Stockton, Calif. <br /> i Telephone: (209) 466-6781 <br /> APPLICATION •FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No <br /> ,�r THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> ✓� ,s'�'� � � (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 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 20979 S. Seaton - one mile North of River MISUS TRACT <br /> West Side <br /> Owner's Name Mrs . Peter Martini <br /> Phone $3$-2301 <br /> Address 20979 S. Sexton - _ c --Es calon, .Cal. <br /> Y <br /> Contractor's Name HENNINGS �BROS. DRILLING CO. , INC.. License X0290813 Phone -522-1.031 <br /> • : 9535 <br /> R' <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN I / RECONDITION /_/ DESTRUCTION /7 <br /> AL <br /> . PUMP INSTLATION / / PUMP REPAIR/ / PUMP REPLACEMENT 17 <br /> Other <br /> • T •� w <br /> DISTANCE TO NEAREST: SEPTIC 'TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER .601 <br /> + PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS y <br /> 'Y.. Industrial f Cable Tool Dia. of Well Excavation lift Q <br /> a.K. <br /> Domestic/private Drilled Dia, of Well Casing <br /> --Domestic/public Driven Gauge of Casing 12 G <br /> f- Irrigation Gravel Pack Depth of Grout Seal 1 -5'0 t- <br />` Cathodic Protection Rotary Type of Grout r - <br /> _� Y YP Bentonite ## <br /> _Disposal Other <br /> Geophysical Other Information Slab by owner, _ �t <br /> Surface Seal Installed By: <br /> PU14P INSTALLATION: Contractor <br /> .Type of Pump H.P. ' <br /> POMP `REPLACEMENT: / / State Work Done <br /> PUN --:REPAIR: / / State- Work Done <br /> DESTRUCTION OF •WELL: Well Diameter._ Approximate Depth <br /> �, ,. /����cribe Materi land Procedure <br /> I hereby agree to comply�w3ti a 1" aws and``regulati s o the' San 3oaq in Local Health District <br /> and the State of California pertaining to or regulating well 'construction. Within FIFTEEN DAYS i <br /> after completion of my work on a new well, Twill furnish the Sari Joaquin Local Health District a <br />. WELL DRILLERS REPORT of the well and notify them before putting the .well in use. The above i <br /> information is true to the-best of my knowledge and belief. I WILL CAJL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL ]INSPECTION. <br /> SIGNED . , INC. TITLE BY ( BKPR <br /> I DRAW PLT PLAN ON REVERS E SIDE) jI: <br /> FOR PARTMENT USE ONLY <br /> PHASE I a -- <br /> APPLICATION ACCEPTED BY r DATE <br /> ADDITIONAL COMMENTS: i <br /> ;�64A <br /> PajFy, IT OUT TNSPECTIO PHASE III ,FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 211-L <br /> -1C_%;2 laze I <br /> E H 1426 .. Rev. 1-74 ' 3/76 2M <br />