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y <br /> �i SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No./7z 310-111 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued -� <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquizi 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. 18f2 and the Ru e6 and Regulation's of the San Joaquin Local Health District. <br /> 369`x°1 <br /> JOB ADDRESS/LOCATION KOSTER RD. _d NORTH OF AIRPORT CENSUS TRACT <br /> Owner's Name CORREIAS. CONSTRUCTION .CO. Phone 835-291+0 <br /> 4 <br /> Address P. 0. BOX 1025 City TRACY <br /> Contractor's Name Hennings Bros . Drilling Co. , Inc. License # 11b322Phone 522-5643 <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN_/ / RECONDITION /_7 DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST- SEPTIC TANK lA SEWER LINES PIT PRIVY <br /> XSEWAGE DISPOSAL FIELD Z0• CESSPOOL/SEEPAGE PIT OTHER Nti <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia, of Well Excavation i6la, <br /> X Domestic/private Drilled Dia. of Well Casing _ 6-t' <br /> < Domestic/public Driven Gauge of Casing 12 GA <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other �X Rotary Type of Grout Bentonite -- <br /> Other Other Information S1,,9& - ,6,/ puvNE'r� # <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: - <br /> State-Wark Done <br /> .ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 3 <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 /> 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. <br /> SIGNED 4 TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �1 t DATE <br /> APPLICATION ACCEPTED BY -- <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTIONPHAS III FINAL INSPECTION <br /> ' INSPECTION BY DATE INSPECTION BY DATE :�/ <br /> CALL- FOR A GROUT INSPECTION .PRIOR TO GROUTING AND FINAL INS CTION. <br /> E H 1426 7/72. 1M <br />