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- <br /> '` SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F ;MR,' ICE USE: p�'� 1601 E.. Hazelton Ave.',, Stockton, Calif. <br /> Telephone: (209) 466-»6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made io 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 Joaquir <br /> County Ordinance No. '1862 and the -Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION <br /> CENSUS TRACT <br /> F <br /> Oamer s Name Phone 9 <br /> 41 W <br /> Address /� / /� Vii(/! r City <br /> Contractor's Name BENNINGS BROS. DRILLING COL INC. License # Phone one 1163 522_561+3 <br /> TYPE OF WORK (Check) : NEW WELL / ( DEEPEN /_7 RECONDITION /_7 DESTRUCTION /_7 <br /> E PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /'7 <br /> Other / / — <br /> DISTANCE TO NEAREST: SEPTIC TANK w SEWER LINES PIT PRIVY <br /> SEWAGE:DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> k — Industrial Cable Tool Dia. of Well Excavation 11s <br /> Domestic/private Drilled Dia. of Well Casing _u <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other <br /> Rotary y Type of Grout 77 <br /> Other Other Information <br />[ PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR: / f State Work Dane <br /> ESTRUCTION 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 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 <br /> TITLE <br /> P ON REVERSE SIDE <br /> F DEPARTMENT USE ONLY <br /> PHASE I / f <br /> APPLICATION ACCEPTED BY DATE r ��/ 7� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION P S I FINAL INSPECTION l� <br /> INSPECTION BY ATE ,11L- T-z INSPECTION BY DATE <br /> CALL F•OR A GROUT .INSPEC ION PRIOR TO GROUTING AND FINAL INSPE ON. <br /> E H 1426 7/72 1MM <br />