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>;- n 1 -SAN JOAQUIN LOCAL HEALTH:llISTRICT I P <br /> FOR '0FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERI-AIT Permit No. 7 Z-- <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . Date Issued g-2- 5 7;- <br /> (Complete <br /> Y(Complete In Triplicate) <br /> Application is <heby' <br /> made to the San Joaquin Local Health District for a permit to construct i <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 a9�Q LQO/1?/,S SPD• CENSUS TRACT <br /> F <br /> Owner's Name �. A, AKA-rsA-,s Phone 4(0 3_,s3p9 <br /> Address Loin/s .RD. City .S-nC,<70/✓ <br /> r <br /> Contractor's Name HENNINGS BROS. DRILLING CO., INC License # Ilb3.1a Phone 512a <br /> MODESTO ,CALIF— <br /> TYPE OF.WORK (Check) : NEW I,�E1,L / T�N RECONDITION /-7 DESTRUCTION /-T <br /> -� PUMP INSTALLATION / / PU.>P REPAIR/ / PUMP REPLACEMENT -/ <br /> Other <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK -+J,. D' SEWER LINES '+ PIT PRIVY <br /> X SEWAGE DISPOSAL FIELD 4L-;Z�_ CESSPOOL/SEEPAGE PIT OTHERS P4s <br /> 'TieA1 P. � <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> - - Domestic/private Drilled Dia. of Well Casing _IVa, <br /> Domestic/public Driven Gauge of Casing a F <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other �_ Rotary Type of Grout SCA/7bNITE O <br /> Other Other Information p� <br /> e l <br /> PUMP INSTALLATION: Contractor 3 <br /> Type of Pump <br /> H.P. to <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / / State Work Done <br /> -.DESTRUCT-NN-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. S <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEi 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 ?jI, /, TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY { <br /> PHASE I , s <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHA II GROUT INSPECTIO PHAS III/FINAL INSPECTIO <br /> INSPECTION BY DATE INSPECTION BY DATE d k <br /> CALL FOR A GROUT INSPECTION PRIG TO ROUTING AND FINAL INSPECTIO I <br /> E H 14264/72 1M <br /> 11/4 C.t.000� - ! / <br />