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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOFi;OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone (209) 466-67$1 . <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. _17,40 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE :ISSUED Date Issued <br /> (Complete In Triplicate) <br /> I Application 4s hereby made to the San Joaquin Local Health District fora permit <br /> tct <br /> and/or install the work herein described. This application is -made in compliancewithnSanuJoaquix <br /> County Ordinance No. 1862 'and the Rules and Regulations of the San :Joaquin Local Health District. <br /> JOB ADDRESS/LOCATIONto ca Q $US.,TRACT <br /> + Ownera Name j:, Aon €cLeJ <br /> Phone <br /> _239-2321 <br /> Address _6048 E. ra e e <br /> City Mantoca <br /> Contractor's Name _Henniags Bro Drillin Co. .Inc. _ License # 20813 Phone 22-10 i <br /> 2 00 W. Rumble Rd. Mod, <br /> TYPE OF WORK (Check):. NEW WELL /2T DEEPEN -/? <br /> RECONDITION j DESTRUCTION /-7 <br /> PUMP INSTALLATION "/ / PUMP REPAIR I 7 PUMP REPLACEMENT 17 <br /> Other /% --- <br /> -DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD _ CESSPOOL/SEEPAGE <br /> PROPEPIT OTHER AO-Z,57'-Z,57'RTY LINE -- PRIVATE DOMESTIC WELL­—. PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial, Cable Tool Dia. of Well Excavation rs <br /> Domes tic/private Drilled Dia. of Well Casing CN <br /> Domestic/public e�Gauge of Casing <br /> Irrigation g �•, -- <br /> Irri " �—A <br /> Gravel Pack- Depth of Grout Seal, <br /> Cathodic Protection X' Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical ` Surface Seal Installed B <br /> PUMP INSTALLATION: '' Contractor <br /> Type .of Pump <br /> H.P. <br /> j PUMP REPLACEMENT L/ State Work Done <br /> TE,REPAIR: j/ / State Work Done <br /> DESTRUCTION 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 orregulatingwell 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 7n GROUTING AND A FINAL INSPECTION. <br /> SIGNED Hennings Bros: Drilling Co. Inc. by TITLE <br /> Sec. , <br /> . DRAW PLOT PLAN ON REVERSE SIDE _ — . <br /> PHASE I FO •DEPARTMENTT MR ONLY <br /> APPLICATION ACCEPTED BY DATE /17. <br /> ADDITIONAL COMMENTS.: r <br /> PHASE I GROUT- INSPECTION PHAS I F AL INSPECTION <br /> INSPECTIQN BY DATE .INSPECTION BY DATE - <br /> E H 1426-... Rev. _144 - _ �`; 1 T <br />