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SAN JOAQUIN LOCAL HEALTH DISTRICT r <br /> IOF,OFFICE USE: 1601 E. Hazel tun A,,., <br /> e.. ,_ 4Cockton, Calif. <br /> _ Telephone : -(209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�-/�7 9 <br /> THIS PERMIT EXPIRES 1 YEAR FROM_DATE ISSUED Date Issued <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 /> = <br /> t - 174--/Y-O-l� <br /> JOB ADDRESS/LOCATION+rAP�FENTER" RD. & POCK LANE-1 MILE WEST OF CENSUS TRACT <br /> Hb1Y 997 SOUTH SIDE OF CARPENTER RD. <br /> Owner's Name HARRY SHREVE Phone <br /> Address 16982 HINTON ST. w City CASTRO VALLEY <br /> Contractor's Name HETININGS BROS . DRILLING "CO.�INC . License # 290813Plione <br /> �525 PLLANDALE A-VE .3 MODESTO. CA . 95350 <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN /_j RECONDITION /-T DESTRUCTION /_ <br /> I PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT / / -- <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK 11 03+ SE14ER LINES PTT PRIVY <br /> i SEWAGE DISPOSAL FIF,LD 1101 CESSPOOL/SEEPAGE PIT OTHEkW,-Z �-Qt <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL w PUBLIC DOMESTIC WELL � <br /> t INTENDED USE TYPE OF WELL. CONSTRUCTION SPECIFICATIGNS <br /> Industrial Cable Tool Dia, of Well Excavation 111r <br /> X Domestic/private Drilled Dia. of Well Casing " PLASTIC <br /> Domestic/public Driven Gauge of Casing 160 WALL <br /> Irrigation _ Gravel- Pack Depth of Grout Seal _ 501 _ <br /> Cathodic Protection X Rotary Type of Crout BENTONITE <br /> Disposal Other Other Information SLAB-BY OWI\'ER <br /> Geophysical Surface Seal Installed By: _ <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> Pn[P REPLACEMENT: / / State Work Done <br /> l — <br /> PUMP• REPAIR: - / / State Work Done } <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> j 1 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 /> 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. T <br /> SIGNED HENNINGS BROS. DRIL . 1 INC. B Y TITLE 10-20-78 <br /> � <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FORD ARTMENT USE ONLY <br /> PHASE, I <br /> APPLICATION ACCEPTED BY DATE �U 7 3,/7 If <br /> ADDITIONAL COMMENTS: . 4 el <br /> PHASE JI GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE 6 Z7 INSPECTION BY DATE <br /> E Ii e!77 <br /> 1426 _Rev. • 1-74 <br /> M <br />