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SAN JOAQUIN LOCAL THD STRICT � <br /> FOSiOFFICE USE 01 E. Hazelton_Ave. , Stockton, Calif. <br /> 4 t Telephone: (204) 466-6781 <br /> AP LICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.� GJ <br /> it <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued 12-.±-_7q <br /> (Complete In Triplicate) <br /> Application i6 hereby made to the San Joaquin Local, Health District for a permit to construct <br /> and/or install the.Wd k 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 AOCATIONa 3b CENSUS TRACT 7�7 <br /> 4�merPs Name �'W Phone <br /> Address.` c�c1;q City <br /> �N z9osl3. -. 522=�03z <br /> Contract_or!s_:Name. HENNINGS BROS. DRILLING COMPANY, INCe License - t'- ne <br /> i <br /> Ir 2900 W, R11L=---RJD- X019910s CAL- 95350, <br /> TYPE OF WORK1(Check): NEW WELL /DEEPEN -/ RECONDITION /-7 DESTRUCTION - <br /> PUMP INSTALLATION /� PUMP REPAIR /� PUMP REPLACEMENT <br /> I�'T <br /> Other/ / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <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 b <br /> Industrial Cable Tool Dia. of Well Excavation V <br /> !/Domestic/private 4--,-Drilled Dia. of Well Casing . <br /> Domestic/public Driven Gauge of Casing �- <br /> _._ =� IrrigaCion Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> 19 Type of Pump Hope <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: <br /> } ��]" State Work Done <br /> ES-TRUCTION OF WELL: Well Diameter 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 regulatix:g 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 TITLE <br /> ii DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY . DATE kX <br /> ADDITIONAL COMMENTS: + <br /> jj' P0ASE 1,1^GROUT-INSPECTION PHASE-1 FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY p` DATE 3L.--14 <br /> E H 1426 Rev. 1-74 - 1-74 2M <br /> i' <br /> I <br />