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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r.0F:OF ICL" USL-: 1601 E. Hazelton Ave, , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 1,SSUED 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 Sar: Joaquin <br /> County Ordinance No. 1862 aid the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 111STE_-WART;.RD`.A AT M0S2DAU Y CENSUS TRACT 2-13 -2-YO -zo <br /> Owner's Name RUDY DELLOSSO Phone <br /> Address 26 W. •STEWART_ED- _ _ <br /> _ - City _ LATHROP <br /> Contractor's Name HENNINGS BROS. DRILLING CO. INC, License # 612 Phone 2 _ ^ <br /> 2500 W: RUMBLE RD. , MODESTO <br /> TYPE OF WORK (Check): NEW WELL /l/_ DEEPEN '/—/ RECONDITION /_/ DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR/—/ PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTICITANK 2= SEWER LINES -,— PIT PRIVY <br /> SEWAGE i DISPOSAL 'FIELD c*So CESSPOOL/SEEPAGE PIT OTHER <br /> I 6� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial i Cable Tool Dia. of Well Excavation rl <br /> X Domestic/private Drilled Dia. of Well Casing A'+, <br /> Domestic/public A Driven Gauge of Casing <br /> Irrigation ' I Gravel Pack Depth of Grout Seal t <br /> _-- Other 4 X Rotary Type of Grout <br /> Other Other Information rte; BY MER <br /> PUMP INSTALLATION: Contractor A g A Lk <br /> Type of Pump H.P. <br /> PUMP.REPLAGEAiENT: <br /> State-Work=Done—�•,�:� . <br /> PUMP 'tEPAIR: / / State Work Done <br /> .DF' TRUCTION OF WELL: Well Diameter <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 k9pw1edge and belief. <br /> SIGNED TITLE <br /> D PAN ON REVERSE SIDE <br /> R DEPARTMENT USE ONLY <br /> P14AS E I <br /> APPLICATION ACCEPTED BY 7 >27ADDITIONAL COMMENTS: iPFIASE II GROUT INSPECTION PHA I I/FI�DATE� <br /> SPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE y <br /> 'E <br /> CALL FOR A-GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPE ION. <br /> E H 1426 el ���-- <br />