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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. <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 Health District. <br /> ALTERNATE WELL SITE <br /> JOB ADDRESS/LOCATION INTERSECTION OF STOCKTON' ST. & THORNTON RD.CENSUS TRACT <br /> COUNTY OF -SAN JOAQUIN & SACRAMENTO BLVD. <br /> Owner's Name THORNTON COUNTY SERVICE AREA NO 12 Phone <br /> Address 222 EAST WEBER AVE. City STOCKTON <br /> Contractor's Name HEENNINGS BROS. DRILLING CO. ,INC. License # 290813 Phone 545-1185 <br /> �525 PELANDALE AVE. MODESTO CA. 95350 -' <br /> TYPE OF WORK (Check) : NEW WELL /S/ DEEPEN /_/ RECONDITION /_/ DESTRUCTION /- _ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT / f <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELI, <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial. Cable Tool Dia, of Well Excavation 21�}r <br /> Domestic/private Drilled Dia, of Well Casing � is <br /> Domestic/public Driven Gauge of CasingA q <br /> Irrigation X Gravel Pack Depth of Grout Seal 501 c <br /> Cathodic Protection Rotary Type of Grout �01.: CONDUCTOR PIPE & CEMEN <br /> Disposal X Other REVERSE Other Information SLAB--BY OWNER <br /> Geophysical ROTARY Surface Seal Installed By: DRILLER <br /> - <br /> X MUNICIPAL <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 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 knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED HENNINGS BROS. DRILLING--C—O.IINC . BY TITLE SEC. <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED DATEs,3C�'"7 <br /> ADDITIONAL COMMENTS: <br /> PHASE IT GROUT INSPECTION PHASE TIT/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE 3-L29 <br /> o/7 /✓a T <br /> E H 1426 Rev. - I-74 G2 U v t- Al 3!p ___�' <br />