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SAN JOAQUIN LOCAL HEALTH DISTRICT � <br /> FORiOFFICE USE: 1601 E. Hazelton Ave.. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> - - APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 75-1�90� <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made toIthe 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 andlthe Rules and Regulations of .the San Joaquin Local Health- District. <br /> .TOE ADDRESS/LOCATION L.�lprP/ , � Gy� CENSUS TRACT <br /> Owner's Name _ Phone FJb- G 9-T <br /> Address � � Zitl,� I G�/i- .- City - �i- <br /> Contractor's Name Hennin -gg Bros, Drilling Co. IIIc. License # 290811 Phone 522-1011 . <br /> 2T00 W, Rumble Rd Modesto <br /> TYPE OF WORK (Check): NEW WELL/ C7 DEEPEN '/_7 RECONDITION /__7 DESTRUCTION /7 <br /> PUMP INSTALLATION /—/ PUMP REPAIR /� PUMP REPLACEMENT f_7 <br /> Other /_7 W <br /> DISTANCE TO NEAREST: SEPTIC YANK 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 <br /> Industrial 1Cable Tool Dia. of Well Excavation - <br /> Domestic/private i Drilled iDia. of Well Casing <br /> Domestic/public Driven Gauge of Casing ,•�_ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection —.Rotary Type of Grout ' <br /> Disposal A Other Other Information <br /> Geophysical 'Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> r i <br /> PUMP REPLACEMENT: / State Work Done <br /> PUMP-'.REPAIR: L�7 State Work Done <br /> ,DES.-xRUCTION OF,WkLL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> E <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 ori 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 /> SIGNEDflennines Bros, Drillingn by TITLE J See <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I •, <br /> APPLICATION ACCEPTED BY, -11 DATE <br /> ADDITIONAL COMMENTS: ; <br /> PHASE II GROUT INSPECTION PHkjE..I FINAL INSPECTION <br /> INSPECTION BY DATE `M-2 a,— INSPECTION' BY DATE -�5 <br /> 1 ^E H 1426 = Rev. 1-74 1-74 2M <br />