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F'OR OFFICE USE: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6783- <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Date Issued�_�-/�-7Z. <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 X <br /> CENSUS TRACT <br /> Owner's Name J= ALEGRE ,(�re 5 , <br /> PhoneX <br /> Address LAMMERS RD. TRACYCity <br /> Contractor's Name HENNINGS BROS. DRILLING -CO. , INC. License # I6322522-5643 t <br /> DESTO CAL. ------- Phone <br /> TYPE OF WORK (Check) : NEW WELL <br /> IXI DEEPEN /_7 RECONDITION /_7 DESTRUCTION /-7 <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPT /-7 <br /> Other -- REPLACEMENT— a <br /> DTSTANCE TO NEAREST: SEPTIC TANK ? S SEWER LINES � <br /> -d-- SEWAGE DISPOSAL FIELD 5CI CESSPOOL/SEEPAGE PIT <br /> /1 <br /> OTHER <br /> INTENDED USE TYPE OF WELL rv ' <br /> Industrial CONSTRUCTION SPECIFICATIONS <br /> Cable Tool Dia. of Well ExcavationM C � <br /> Domestic/private Drilled Dia. of Well Casing n�rn <br /> Domestic/public -__-__r Driven Gauge .of Casing 12 mer v E <br /> Irrigation Gravel Pack Depth of Grout Seal D ? <br /> Other d _ <br /> Y Rotary Type of Grout <br /> Other Other Information Sa Cra.� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump j <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> j <br /> PUMP REPAIR° <br /> State Work Done <br /> RESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure APPr.oximate Depth <br /> k <br /> I hereby agree to comply wrath all laws and regulations of the San Joaquin- Local".health District <br /> ind the State ,of California pertaining to or regulating well cons-traction:. -Within FIFTEEN DAYS f <br /> tfter completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> 1ELL DRILLERS REPORT of the well and notify them before putting the welkin use.' The above <br />'.nformation is true to the best of my knowledge and belief. = B y <br /> SIGNED HENNINGS BROS. DRILLING COLI INC. �e!VL- <br /> (DRAW PLOT PT.AAi TITLE Bookkeeper, <br /> ON REVERSE SIDE <br />'HASE I FOR DEPARTMENT USE ONLY - <br /> _.Y- <br /> PPLICATION ACCEPTED BY - - - <br /> DDITIONAL COMMENTS: DATEu S ' <br /> PHASE I R T INSPECTIO PHASE II INAL INSPECTIO <br /> NSPECTION BY ATE 2 0 INSPECTION BY } <br /> .2 A <br /> CALL FOR A GROUT INS ECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1425 <br /> 7/72 1M <br />