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1 <br /> SAN JOAQdN' LOCAL HEALTH DISTRICT <br /> FOW,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �64� <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. 31862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Stow Road � � CENSUS TRACT <br /> Owner's Name Mrs . Nunoz Phone 463-0212 <br /> Address 1567 Newport Rd. - City Stockton,Cal <br /> Contractor's Name Hennings Bros . Drilling Company,, TnEfcense # 290813 Phone 522-1031 . <br /> _ _- 2500 Test Rumble Rd. Modesto, Cal. <br /> TYPE OF WORK (Check): NEW WELL A7! DEEPENT7 7 RECONDITION /-7, DESTRUCTION /`7 <br /> PUMP INSTALLATION / / PUMP REPAIR /% PUMP REPLACEMENT /-7 <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC TANK 0 SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT VIRWR <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 0r' <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driy_en Gauge of Casing <br /> X Irrigation �— Gravel Pack Depth of Grout Seal <br />` Cathodic Protection �^ Rotary Type of Grout <br /> Disposal , Other Other Information a owner <br /> Geophysical Surface Seal Installed By: ^ t <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMPI.REPAIR: / / State Work Done <br /> ES•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 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-beat of my knowledge and belief. I WILL/WL FOR A ,GROUT INSPE21ION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. by <br /> SIGNED ynj ngg BroS. Drilling Co. , Inc. TITLE �A(DRAW PLOT PLAN ON REVERSE SIDE cpr <br /> - -- - --- - FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 9 3 <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE - <br /> R <br /> t E H 1426 Rev. 3-74 1-74 2M <br />