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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE. USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> tti Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.J2-2/5-V <br /> THIS PERMIT EXPIRES 1 YEAR PROM DATE ISSUED Date Issued, Z-7� <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> E 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 Graves Avenue CENSUS TRACT <br /> i Owner's Name Charles Travaille Phone599-4497 <br /> Address 12136 E . Graves City Manteca <br /> Contractor's Name Hennings Bros. Drilling Co. s Inc. License # 116322 Phone 522--5643 <br /> 2500 W. Rumble Rd. Modesto Cal. 95350 <br /> TYP--OF-WORK--(Che-ek)-- —NEW_WELL.-/-Z DEEPEN-/- -RC© DON�� ST-RTCION�/I- � <br /> PUMP INSTALATION :/ / PUMP 'REPAIR <br /> / / PUMP REPLACEMENT /-7 , <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> j INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 2411 <br /> Domestic/private Drilled Dia. of Well Casing 1 ss Q <br /> "Bomestic/public Driven. Gauge of Casing <br /> X_ Irrigation r Gravel Pack Depth of Grout Seal <br /> Other X Rotary Type of Grout <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> a <br /> PUMP REPAIR: J / State Work Done <br /> ESfikIJGT10N�F'WELL.° "Well Diameter "'"""" {Approximate DepthT <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 workx '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 /> Hennings Br �o � <br /> Drilli � f Inc. <br /> ; SIGNED //lGLTITLE Bookkeeper <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FO DEPARTMENT USE ONLY <br /> PHASE I 12 -� Z-7 <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P �IIffALINSPECTION <br /> INSPECTION BY DATE INSPECTION BY TE <br /> CALL FOR A,GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. -)4,D <br /> E H 1426 7/72 1M <br />