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1 SAN JOAQUIN ,LO Al HEALTH DISTRICT A <br /> f FOT;'OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 4666781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7S.300& <br /> THIS PERMIT EMPIRES 1 YEAR FROM DATE ISSUER Date Issued <br /> i (Complete In Triplicate) T" <br /> Application- is hereby made to the San Joaquin Local Health District fora 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 _gest Grantline Rd. 1st place west of Paarraad- gS TRACT S <br /> Owner's Name F. M. Van Winkle Phone$35—x.760 <br /> Address 7119 W. Grantline Rd. City ' Tracy, Cal. <br /> - <br /> Contractor's Name Hennings t Bros . Drilling Co. , Inc License # 290813 Phone 522-1031 <br /> e - Rd. Modesto a if. 95350 <br /> TYPE OF WORM (Check): NEW WELL '/X7 DEEPEN '/_7 RECONDITION '/-7 DESTRUCTION /7 <br /> AL <br /> PUMP INSTLATION '/ / PUMP REPAIR/� PUMP REPLACEMENT /7 <br /> I .DISTANCE TO NEAREST: SEPTIC �TANK SEWER LINES`' PIT PRIVY <br /> SEWAGE,.DISPOSAL'' FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE .. PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial. Cable Tool i Dia. of Well Excavation 11'� <br /> _ y Domestic/private I Drilled :]Yia. of Well Casing 6,t Plasti <br /> E Domestic/public t Driven Gauge of Casing <br /> k Irrigation Gravel. Pack Depth of. Grout Seal 50.1 <br /> r Cathodic Protection*,' Rotary Type of-Grout ` en onibe <br /> ._Disposal 1 Other Other Information -Slab by owner <br /> Geophysical. Surface Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type-.of Pump H.P. <br /> PUMP REPLACEMENT:: / / State Work Done <br /> PUMP .REPAIR: /_/ �SateTWork-_Done <br /> bE$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 .1 <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 pu4ing..the..well. in.use.... .The above <br /> information is true to the•best-of my..knowledge and belief.A I WILL CALL FOR A 'GROUT INSPECTION <br /> PRIOR TO GRO ING AND IN1 �INSP CT ION. �' <br /> SIGNED " - . TITLE <br /> lDRAW PLOT PLAN ON REVERSE SIDE <br /> m?2RL D MENT i_USE ONLY,t 1 <br />.PHASE I - <br />'APPLICATION ACCEPTED Y <br /> DATE �7 S <br /> ADDITIONAL COMMENT -7----� <br /> PHA II GROPT--IWSPECTION T II NAL INSPECTION _ <br /> INSPECTION BY - DATE INSPECTIO DATE 5 <br />, ., E--H_1426 Rev. .1--74 17< >m <br />