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/vo r GUn-1Pf-�-T"rz r- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT fNS`, P <br /> FOE,�O,;.,JICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. ND c.;,( T'fUq r <br /> d:.� W To— <br /> Telephone: (209) 466-$781 (Sntn <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT 7-13 1 <br /> �/� THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 2 - /8'-77 <br /> � (Complete In Triplicate) <br /> Application is hereb 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 /> JOB ADDRESS/LOCATION 21117 . Harrold Ave.--Lmi North of River Rd.VNSUS TRACT <br /> west side <br /> Owner's Name Jim Alexander Phone $ $-2 516 <br /> Address 21317 S . Harrold Ave. City Escalon <br /> Contractor's Name Hennings Bros. Drillin Co. lnc. License # 2O81_3Phone 522-10-31 <br /> 00 W. humble Rd. Mod. i <br /> TYPE OF WORK (Check): NEW WELL /X,7 DEEPEN '/ / RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT /-7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD 1!2 CESSPOOL/SEEPAGE PIT OTHER 44--/0 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL pp <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ry <br /> Industrial Cable Tool Dia. of Well Excavation ill, <br /> X Domestic/private Drilled Dia. of Well Casing _ 6" pla stiff° <br /> Domestic/public Driven Gauge of Casing 160 wall <br /> _ <br /> Irrigation _ _ _ _Gravel Pack_ ,__ _Depth_of_Groin. -Seal- --5. 09 <br /> Cathodic Protection X Rotary Type of Grout Bentonite <br /> Disposal Other _ Other Information Slab-bv owner <br /> Geophysical Surface Seal Installed By: driller <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump C H.P. <br /> PUMP REPLACEMENT: , / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF_-WELL: Well Diameter Approximate Depth _ <br /> escribe to ia1 an Pro edure <br /> - <br /> I hereby agree t�comply with all laws and regula ons of the San J quin Local Health District <br /> F and tfetate'of 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. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED BFUS. DhiLLING • I INC. BY TITLE " <br /> (D W- P. iT PLAN ON RE FRSE SIDE <br /> FOR ptTARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHAW II U INSPECTIO PHAS II / AL INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE ,3 <br /> E H 1426 Rev. 1-74 0/ <br /> rel/i�.� <br />