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SAN JO,AQUIN LOCAL HEALTH DISTRICT ---� 14� I <br /> FOY-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 :2� :73 <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 /> JOB ADDRESS/LOCATION 3912 -Sunny Rd. Stockton CENSUS TRACT , <br /> Owner's Name James L:. Hopper Phone 462-6925 ; <br /> Address 3912 Sunni Rd. City StCktori <br /> i <br /> Contractor's Name Hennings Bros. Drilling Co. Inc. License #116322 Phone 522--5643 <br /> Rumble Rd. Modesto, Cali . <br /> 'TYPE OF WORK (Check): NEW WELT, / DEEPEN '/ / RECONDITION / / DESTRUCTION /`77 <br /> PUMP INSTALLATION /—/ PUMP REPAIR /—/ PUMP REPLACEMENT /,7 <br /> Other / / <br /> N. <br /> DISTANCE TO NEAREST: ; SEPTIC TANK SEWER LINES PIT PRIVY T T <br /> X�/ <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER C1V <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 3i <br /> Industrial Cable Tool Dia. of Well Excavation 1 1" <br /> Domestic/private Drilled Dia. of Well Casing _ -�� 611 <br /> Domestic/publics Driven Gauge of Casing 12 Ga <br /> Irrigation Gravel Pack Depth of Grout Seal 5Q I <br /> Other # Rotary Type of Grout Bgntonite <br /> ' Other Other Information Slab by 0-wner <br /> PUMP INSTALLATION: Contractor 7 <br /> Type of Pump H.P. <br /> f <br /> PUMP REPLACEMENT: / / State Work Done <br /> a PUMP UPAIR: / / State Work Done ; <br /> ,DFgTRUCTION 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 /> f and the State of California pertaining to or regulating well "constructi.on. 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 /> SIGNED /J TITLE Pres. <br /> ISX (DRAW PLOT PLAN ON REVERSE SIDE) <br />'i FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED 1YAZZLI:IA�� DATE * Z�/ <br /> ' ADDITIONAL COMMENTS: <br /> PI E I 0 T INSPECTION PHAS / AL INSPECTION <br /> INSPECTION B ATE 3 INSPECTION BY ATE ' /l c <br /> # CALL FOR A GROUT INS ION-t:kIOR TO GROUTING AND FINAL INSPECTION. <br /> ' rte' 1M <br /> E H 1426 5/7 3 - <br />