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0 r5x� / <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT' <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton., Calif. <br /> Telephone: (209) 466W-6781 <br /> ' APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit Na. Z z <br /> t <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued .S�3�-Z? <br /> Application is hereby made tI (Complete In Triplicate) <br /> o "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 <br /> G I-AZ7�RC CENSUS TRACT <br /> Owner's Name <br /> Phone <br /> Address v0/� <br /> i BR S. DRILLINGCity �N/�C ------ <br /> Contractor's Name i C©�� '��� <br /> IMBLE AD <br /> License # // �� phone�j;`t S4 <br /> 116322,__ <br /> TYPE OF WORK (Check): NEW WELT,- DEEPEN —PUMP <br /> /_7 DESTRUCTION /? <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other — e <br />` DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial .1 Cable Tool Dia, of Well Excavation ' <br /> Domestic/private I Drilledr• <br /> Dia. of Well Casing <br /> Domestic/public 4 Driven Gauge of Casing <br /> Irrigation ! Gravel Pack� <br /> Other Depth of Grout Seal <br /> Rotar � ! <br /> _ Y Type of Grout <br /> Other Other Informatioi <br /> PUMP INSTALLATION: -Contractor <br /> Type of Pump <br /> [ H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: 1-7 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 myvwork 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 /> HE'NNINGS BROS. DRILLING CO., !N 4 <br /> SIGNED TITLE <br /> 2500 W. RUMBLE ROAD r <br /> W PLOT PLAN O�NRUEVERO SE SIDECALIF. LICENSE 11632FOR DEPARTMENT SENLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE GROUT INSPECTION PH-AS i/ INAL INSPECTION <br /> INSPECTION BY DATE �^ 2.f"' 7� INSPECTION BY DATE Gx 2 _ <br /> CALL FOR A GROUT INSPE ION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 <br /> 7/72 1M <br />