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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF. OFFICE USE: 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 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 /> ,TOB ADDRESS/LOCATION WOODWARD &SMC KINLEY RDS. CENSUS TRACT <br /> Owner's Name Phone <br /> Address 1799 ME _ City SAN' JOSR A <br /> Contractor's Name HEN1VINGS BROS. DRILLING CO. License # 290813 <br /> INC. _� :� (4.hone 22-1641 <br /> 2-5M W1 RITMF3IZ RD__ MODFETO <br /> TYPE OF WORK (Check) : NEW WELL /X/ DEEPEN '/—/ RECONDITION /_/ DESTRUCTION /-7 <br /> PUMP. INSTA LATION J ! PUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK Sev SEWER LINES PIT PRIVY <br /> XSEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing 16T- <br /> Domestic/public Driven Gauge of Casing GA <br /> X Irrigation _ X Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout. <br /> Other Other Information bX Owner <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> -PUM£'-REPLA.CEMENT: <br /> State'Work- Bone <br /> PULP 'tEPAIR: / J State Work Done <br /> ,DFGTRUCTION 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 tru to the best f my knowled a and belief. <br /> SIGNEDi�rjTITLE <br /> (DRAW JOT PLAN ON REVERSE SIDE} <br /> PHASE I R EPART11ENT USE ONLY <br /> APPLICATION ACCEPTED DATE <br /> ADDITIONAL CO1,=NTS: <br /> PHASE II GROUT INSPECTIONP -SE--- I/FINAL INSPECTION <br /> INSPECTION BYDATE INSPECTION BY6_4 DATE <br /> I <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSP ON. <br /> E H 1426 _ �_ 5/731M <br />