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h 4' l/ 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.ZL,, 3A/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (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 I-Ieal.th District. <br /> JOB ADDRESS/LOCATION 15252 STEINTEGUL RD. CENSUS TRACT <br /> Owner's Name LINDON MORGAN Phone .869-2Z23 <br /> Address =. 1506 MITCHELL AVE. City ESCALON <br /> Contractor's Name Hennings Bros . Drilling Co. Inc. License #116322 Phone 522--5643 <br /> 2 00 W. Rumble Rd. Modesto Ca11f.Q53 0 <br /> TYPE OF WORK (Check) : NEW WELL /x/ DEEPEN/_/ RECONDITION /—/ DESTRUCTION /-7 <br /> AL <br /> PUMP INSTALLATION f-1/ PUMP REPAIR /—/ PUMP REPLACEMENT /-7 <br /> Other / J <br /> DISTANCE NEAREST: SEPTIC TAiNKO SEWER LINES , PIT PRIVY <br /> SEWAGE DISPOSAL"FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE F WELL CONSTRUCTION SPECIFICATIONS Aj <br /> Industrial Cable Tool Dia. of Well Excavation 110 <br /> XDomestic/private Drilled Dia. of Well Casing 6ill <br /> Domestic/public Driven Gauge of Casing 12 Ga <br /> Irrigation Gravel Pack Depth of Grout Seal 0 <br /> Other X Rotary Type of Grout Bgjatonite <br /> Other Other Information ab by owner ` <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump, H.P. _Z. <br /> PUMP REPLACEMENT: /7 State Work Done it" <br /> PUMP UPAIR:. / / State Work Done b S <br /> ,DF'-TRUCTION 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 try 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 he best of my knowledge and belief. <br /> SIGNED 11 TITLE <br /> {DRA <br /> IT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY ��1\ W� . .,.� DATE �3 <br /> ADDITIONAL COMMENTS: - <br /> P�SE �IGRO�UTIN�SPECT�103\1 P II / NAL INSPECTION <br /> INSPECTION BYINSPECTION DATE -1 <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426- 5,/731M <br />