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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR--OFFICE USE: 1601 E. Hazelton Atie. , Stockton, Calif. <br /> Telephoner (209) 466-6781 a <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No, <br /> Q THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ; Date Issued <br /> ��' -(Complete In Triplicate) <br /> Application is hereby de 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 t VENSUS TRACT 910 i <br /> Owner's Name BAMS BAAL ESTATEPhone 823_3148 <br /> Address 344 East Yosemite venue City Manteca <br /> Contractor's Name HENNINGS BROS. DRILLING CO. INC . License #116322 Phone 522--5643 <br /> TYPE OF WORK (Check) : NEW WELL fig DEEPEN '/_7 RECONDITION /? DESTRUCTION /? <br /> AL <br /> PUMP INSTLATION /—/ —PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK /001 SEWER LINES /y0 PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER t <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing _- <br /> Irrigation Gravel, Pack Depth of Grout Seal <br /> Other Rotary ..Type of Grout <br /> Other Other Information ' ` <br /> PUMP INSTALLATION: Contractor zu 1 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done I: <br /> T <br /> ESTRUCTION 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. <br /> 1 <br /> SIGNED TITLE <br /> TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I DATE _ �' _2 Z <br /> APPLICATION ACCEPTED BY -- - ---- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BYDATE INSPECTION BY DATE -11-2Z- <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 4/72 1M <br /> F <br />