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' . ga) / <br /> SAN JOAQUIN LO+�C�AL.,HEAT.,TH DISTRICT <br /> r'u OFFICE USE: 1601 E. Hazelton T1e. , Stockton, C - <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 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 Ru a n�_Regulations of the San Joaquin Local Health District. <br /> f <br /> XB ADDRESS/LOCATION Mossdale Y s / CENSUS TRACT <br /> Owner's Name DELMAR AUCH of Phone 835-2593 <br /> Address 1369 LINCC.LN BLVD City TRACY , CAL <br /> Contractor's Name HENNINGS BROS. DRILLING CO. ING. Lice se # 290813 Phone 522--1031 <br /> 2500 WEST RGIVIBLE RD. MUD=U � UA M' 50 <br /> TYPE• OF WORK�(Check) : NEW WELL DEEPEN '/ / RECONDITION_/� DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR/ / PUMP REPLACEMENT I_T <br /> Other / / — <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK d6o SEWER LINES PIT PRIVY <br /> SEWAGE DISPOtAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS • <br /> Industrial Cable Tool Dia. of Well Excavation 11st <br />'r Domestic/private Drilled Dia. of Well Casing 6 tr las tic <br /> Domestic/public Driven Gauge of Casing 160 W (� <br /> Irrigation Gravel Pack Depth of Grout Seal 501 _{ <br /> Cathodic Protection Rotary Type of Grout Bentonrte <br /> f er Information -Slaby onwer <br /> Disposal Other Oth <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP .REPAIR: / / State Work Done -- <br /> DESTRUCTION 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. I WILI,,CALL FOR A GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. BTJ , <br /> SIGNED • , INC • _ TITLE KPR 13 76 <br /> D W. 'L T PLAN-ON .RE RSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I s <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE /FINAL INSPECTION cc <br /> INSPECTION BY DATE ,,, INSPECTION BY <br /> 4 <br /> 'iEv v7 Ft-!%�'-� / 376 24 <br /> F T3 1G9fi Racy_ 1-74 Gf.�L <br />