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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone : (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 772-741W <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued il-k- 7 7 F <br /> (Complete In Triplicate) { <br /> 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 /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> 2 <br /> Address City ��:. <br /> a <br /> Contractor's Name HENNING_S BROS-. DRILLING CO'.,INC. License # 290813 Phone 522.1031 <br /> 2 00 W. RUMBLE RD. MOD. <br /> TYPE OF WORK (Check) : NEW WELL /X/ DEEPEN /_/ RECONDITIONn-//. \DESTRUCTION /-7- <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> / <br /> Other- /— I <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> S05 F SEWER LINES PIT PRIVY J <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC- WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS • <br /> Industrial Cable Tool Dia. , of Well Excavation 2611 <br /> Domestic/private Drilled Dia. of Well Casing 14" <br /> I <br /> Domestic/public Driven Gauge of Casing _ 3Z16 GA- <br /> X Irrigation X -- Gravel Pack Depth of Grout Seal <br /> Cathodic Protection _ Rotary Type of Grout �» <br /> Disposal Other Other Information SLAB-BY OWNER <br /> Geophysical Surface Seal Installed BX: » ' <br /> PUMP INSTALLATION: Contractor 4 . <br /> � <br /> Type of Pump H.P. <br /> h <br /> PUMP. REPLACEMENT: / / State Work Done, <br /> PUMP .REPAIR: / / State _Work Done <br />`DES•TRUCTION OF WELL:. t Well Diameter Approximate Depth <br /> Y ®moi. <br /> A , Y ,� 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 work on a new well, I will furnish the San Joaquin Local Health District a <br /> jWELL 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 /> S.I GNED A <br /> n TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br />` PHASE I <br /> 1APPLICATION ACCEPTED BY DATE 0 <br /> ADDITIONAL COMMENTS: * <br /> PHASE TT GROUT INSPECTION/- PHAS <br /> 1FITjPX INSPECZ19N2 <br /> 1INSPECTION BY DATE INSPECTION BY DATE�Q <br /> y * S _1r . 3IR 2M <br />