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_ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR- OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> F Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.,_-'3 <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued1 73 <br /> f (Complete In Triplicate) <br /> Application is hereby 'inade '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 Joaquil <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION Yo Grooms Rd. CENSUS TRACT ` <br /> Owner's Name Richard Cambs -_- _ _ Phone <br /> Address j P. 0. Box 58 City Valley Home <br /> Contractor's NameHennin s Bros. Drilling Co, Inc. License # 116322 phone 522--5643 <br /> . U e KCL* MOCLU�3kv <br /> RECONDIT3QN --RUGTONB <br /> MO�wORx.-(_Che.ck)..4�vEW�—ELL../:./ DEEPEN./ _ _/ TDES _ <br /> ' PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEME-TyNT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ PIT PRIVY <br /> ;SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation lot' <br /> Domestic/private Drilled Dia. of Well Casing 6iri L <br /> Domestic/pub lic'IL. Driven Gauge of Casing 12 Ga (� <br /> Irrigation i3 Gravel Pack Depth of Grout Seal <br /> Other^ Rotary Type of Grout <br /> Other Other Information <br /> a <br /> PUMP INSTALLATION: Contractor <br /> :s Type of Pump H.P. <br /> 'UMP REPLACEMENT: / / State Work Done <br /> � I <br /> PUMP REPAIR: ,; / State Work Done { <br /> {,DESTRUCTION OF WELL: j Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 7� <br /> �. I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> rand the State �o€ 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 /> Hennings Bros. D ' lung Co. I nc. <br /> SIGNED TITLE <br /> ` (DRAW PLOT PLAN ON REVERSE SIDE <br /> FO D TMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPT DATE <br /> - <br /> ADDITIONAL COMMENTS: ' <br /> ROUT INSPECT ON PHASE jJ114INAL INSPECTION <br /> INSPECTION BY7- DATE INSPECTION BY BATE <br /> R TO GROUTING AND FINAL INSPECTION. <br /> GALL FOR A GROUT I'N' SPECTION -PRIOR � <br /> E H 1426 7172,-- IM G�- <br />