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~ ' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FORIOFFTCE USE: If. 16el E. Hazelton Ave. , Stockton, Calif. <br /> ` Telephone: (209) 466-6781 <br /> + APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ? - � <br /> �i <br /> f THIS PERMIT EXPIRES l YM. FROM DATE ISSUED Date Issued7� <br /> ! (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Heath District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> ,3.yg� t/4NJlev RIO s.- 470(_ Kyo <br /> i JOB ADDRESS OCATION igaa_jase <br /> CENSUS TRACT <br /> i - <br /> Owner's Name Don C o s e Phone 83 5-0966 <br /> i' <br /> Address -P. 0. Box 326 - City Tracy, Cal. <br /> Contractor's Name Hennin s Bros. Drilling Co Tnc C-57 <br /> • • License ?� Phone 522-5663 <br /> TYPE OF WORK (Check) : ii NEW WELL X-7 DEEPEN 47 RECONDITION /? DESTRUCTION /7 <br /> /? <br /> I' PUMP INSTALLATION / / PUMP REPAIR PUMP REPLACEMENT /—f <br /> Other /_7 -- <br /> DISTANCE TO NEAREST: SEPTIC TANK ft, SEWER LINES M PIT PRIVY /c" <br /> SEWAGE DISPOSAL FIELD 1601 <br /> CESSPOOL/SEEPAGE PIT OTR <br /> PROPERTY LINE --PRIVATE DOMESTIC WELL ES <br /> PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �1 <br /> Industrial .I1 Cable Tool Dia. of Well Excavation <br /> _X Domestic/private,- Drilled Dia. of Well Casing <br /> Domestic/public !� Driven Gauge of Casing 12 Ga V <br /> Irrigation Gravel 'Pack Depth of Grout Seal 01 <br /> Cathodic Protection X Rota T Bent ite <br /> a Rotary Type o€ Grout- <br /> Disposal i Other s` Other Information Slab by., owner <br /> Geophysical '� - <br /> _ Surface Seal Installed By: Egnningg Bros, <br /> 'i <br /> Pte' INSTALLATION: I;Contractor Drilling Co. , Inc. <br /> i :Type of Pump H.P. <br /> li <br /> } PUMP REPLACEMENT: State Work Done 6 —s - zy <br /> FUI��.REPAIR:,�_� �, State.-Work_Done <br /> �, ESmRUCTION- OF WELL: ''Well Diameter <br /> 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 <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my ;;rork' on a new well$ I- will furnish the San Joaquin Local Health District a <br /> lWELL DRILLERS REPORT of the well and notify them before putting the.-well in.use.. The above <br /> information is true to •;the,best off-my knowledge and belief:""" WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL I SPECTION. <br /> ' ,SIGNED,. L`- �TITLE _ <br /> �I. RAW PVOT PLAN ON REVERSE SIDE 8 Pte— <br /> FOR DEPARTMENT USE ONLY <br /> BASET <br /> APPLICATION ACCEPTED .BYE DATE <br /> ADDITIONAL COMMENTS: I� --.— <br /> PHASE TT GROUT INSPECTION P FINAL INSPECTION <br /> PECTION BY DATE INS�ECTT N B 1 DATE - -7 <br /> f <br /> 11'1426 <br /> Rev. 1-74 <br /> L—. ( y .. _ 1-74 2M <br />