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r_ SAN JOAQUIN LOCAL HEALTH DISTRICT / 1� <br /> FOE OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. �1J <br /> Telephone: (209) 466-6781 <br /> y ,�,.= - &APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. y'--23 A/ <br /> 1 THIS PERMIT EXPIRES. 1 YEAR FROM DATE ISSUED Date Issued ,,/ 7S <br /> (Complete In Triplicate) <br /> f Application is hereby 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 and Regulations of the San -Joaquin Local Health District,. <br /> ` J <br /> � 30B ADDRESS/LOCATION RANSEN RD_J �BMI- `EPENSUS TRACT <br /> Owner's Name Phone 8 I a-5466 _ <br /> , :Address 23M4 HANSEN RD. City TRACY <br /> 0 -- <br /> Contractor's Name HENINGS BROS._ DRILLING CO. $INC. License_#V29081 Phone 522- _. - <br /> OCA-,:-W-.--RUNOLE�-RD. MODE-STt3 <br /> }TYPE OF WORK (Check): NEW WELL AT DEEPEN /? RECONDITION /_T DESTRUCTION- <br /> E PUMP INSTALLATION '/ / PUMP REPAIR•/� PUMP REPLACEMENT /7 <br /> lar Other /7 <br /> DISTANCE TO NEAREST: SEPTIC TANK 16� SEWER LINES, PTT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> i PROPERTY LINE —PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL <br /> INTENDED USE P TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation 1111 <br /> `x Domestic/private Drilled Dia. of Well Casing 6_5z81? . Q <br /> Domestic/public Driven Gauge of, Casing <br /> Irrigation Gravel. Pack Depth of Grout Seal � <br /> Cathodic Protection X - Rotary Type of Grout RPntnni tP _ <br /> Disposal ! Other Other Information _ Owner <br /> Geophysical Surface Seal Installed 'B i <br /> PUMP INSTALLATION- Contractor <br /> F, <br /> Type of Pump H.P. <br /> ` PUMP REPLACEMENT: . / / State Work Done <br /> • _,r•,ra-.�,..D... .�..: ._�.,.. :.. ;_-�-w�w�- .w _ .•�e.+�w-=_-� --r--i� _ ...- \ �r:.. -�;..n.�.-"-.'.;r„�—:-....:�,x,.rsr�.�.sa... <br /> �PU '.REPAIR: /� State Work Done <br /> RE&TRUCTION OF WELL. Well Diameter Approximate Depth <br /> G Describe Material and Procedure <br /> r <br /> I her agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> Land the State of California pertaining to or regulating well 'construction. Within FIFTEEN DAYS <br /> after completion 'of aiy, work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well aad notify them before putting.the.,well. in.:use.... The above <br /> : information is true to•the•best •of my.-knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> `PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> f SIGNED EINNINaS BE02, DRILLING CO. INC . BY TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTT USE ONLY <br /> PHASE I <br /> APPLICATION' ACCEP DATE ^ �-3 <br /> ADDITIONAL CO <br /> P SE GROUT INSPECTION P I NAL INSPEgig <br /> sINSPECTI _ DATE - 7 7 INSPECT O B DATE zs <br /> Y <br /> M <br /> E_H 1426 Rev. 1-74 <br />