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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOE OFFICE tL`SE:' ., 161 E. HazeltonAve:; 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 Issued4 <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)(A 8 �j 4 S X/ �— CENSUS TRACT <br /> h <br /> Pone$3 t- 2 S"3 <br /> Owner's Name DEL AIICH 1 <br /> Address 1369 LINCOLN BLVD'. City TRACY <br /> Contractor's Name HENNINGS BROS. } License # 29D313_ Phone '522-1 1 <br /> DRILLIN G CO. INC. <br /> 2 500 W. RUMBLE RD'. 3 MOD. <br /> TYPE OF WORK (Check) : NEW WELL T/T DEEPEN/ / RECONDITION /_7 DESTRUCTION /_ <br /> PUMP INSTALLATION/ / ,PUMP REPAIR/ j PUMP REPLACEMENT /? <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK pd SEWER LINES /p PIT PRIVY <br /> X SEWAGE DISPOSAL' FIELD /d4- CESSPOOL/SEEPAGE PTT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL -P-0 PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation lift <br /> L <br /> Domestic/private Drilled Dia. of Well Casing " l <br /> aStiC <br /> jDomestic/public Driven Gauge of Casing 160 <br /> Irrigation Gravel Pack Depth of Grout Seal 50' — r <br /> Cathodic Protection __JX — Rotary Type of Grout BENTONITE <br /> Disposal Other Other Information SLAB-- BY OWNER <br /> Geophysical Surface Seal Installed By: DRILLER <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> I PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL:- Well Diameter Approximate Depth <br /> I� Describe Material and Procedure <br /> f 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 A 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 /> SIGNED BENN N S , ING . BY TITLE SEG. <br /> DRAW PLOT PLAN 'ON RE FRSE SIDE) I; <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE 3'� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III/FINAL INSPECTION <br /> INSPECTION BY DATE ' INSPECTION BY DATE I Z-X1_'2c <br /> _ 2M <br /> E H 1426 Rev. 1-74 <br />