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tiYrtSAN JOAQUIN LOCAL r; <br /> FOR '07sFICE USE; 1601 E. Hazelton Ave. , Stockton; Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7 y 1,? Kj <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED : Date Issued Lf-2 5 7i <br /> (Complete In Triplicate) p, <br /> Application itheby 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 andel Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION o1' 4?40 Z00Mj,5 /r D. CENSUS TRACT <br /> Owner's Name LLA. LAKA-rsmS Phone 4L&3-,009 <br /> Address <br /> Address LOnM/S ./PD. City ,STd( KTaN <br /> J <br /> r <br /> Contractor's Name <br /> HENNINGS EROS. DRILLING CO., INC License # //b3 Phone R -S(vy3 <br /> MODESTO CALIF �� <br /> TYPE OF WORK (Check) : NEW WELL / L N RECONDITION /� DESTRUCTION /7 <br /> PUMP INSTALLATION/ / PUMPREPAIR/ / PUMP'REPL'ACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK I±LSQ' SEWER LINES ' PIT PRIVY <br /> X SEWAGE DISPOSAL FIELD 4,af CESS 0/SEEPAGE PIT OTHER SL.&Q 043 4 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing lava- <br /> Domestic/public Driven Gauge of Casing /a <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout 1?GM7 V1TE O <br /> Other Other Information r 1 <br /> PUMP INSTALLATION: Contractor 3 <br /> Type of Pump H.P. I^ 9 <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: /-7 State Work Done <br /> ,PES3'Rt3CrTi-0N-OF-WELL-t--^idea1-Diameter Approximate" De'p'th <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 /> TITLE <br /> SIGNED /y� pi .moi.. .,n�4/ <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR. DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY Y�iy�/,p az� — DATE <br /> ADDITIONAL COMMENTS: !i <br /> PHAS6 II GROUT INSPECTIO PHAS • III/FINAL INSPECTIOIJ <br /> INSPECTION BY DATE INSPECTION BY DATE �'2-- <br /> CALL FOR A GROUT INSPECTION PRIG TO ROUTING AND FINAL/INSPECTIO . <br /> E H 1426 /0/A GG�ae� 4/72 IM <br />