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SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> FOL OFFICE USE: !"v 1601 E. Hazel ton'1.4ve: Stockton, Calif. <br /> Telephone: (209) 466-6781. <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7Z_Z2S&) <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 /> JOB ADDRESS/LOCATION 18900 E. Mello d.•�Between Mur h & WagnerUS TRACT <br /> South side <br /> Owner's Name Lee Halmark Phone <br /> Address 18 00 E. Me1JDRd. City Ripon <br /> r„ <br /> Contractor's Name Hennin3 S Bros. Drilling Gib.' Ine . License # X9081 Phone - 2-1031 <br /> 2500 -W. Bumble Rd. Mod. ' <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN '/ / RECONDITION / / DESTRUCTION /-J <br /> PUMP INSTALLATION/ / PUMP REPAIR/ / PUMP REPLACEMENT /7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK •4 SEWER LINES PIT PRIVY �4�Cci�ea-a <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER .5 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL 1 <br /> INTENDED USE TYPE OF'WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial -Cable Tool Dia. of Well Excavation 2011 <br /> Domestic/private Drilled Dia. of Well Casing 12" <br /> Domestic/public ', k Driven- Gauge of Casing -.1/16 GA <br /> t X Irrigation X Gravel Pack Depth of Grout Seal n olae <br /> Cathodic Protection X Rotary Type of Grout <br /> It Disposal Other Other Informationnab wner <br /> Geophysical Surface Seal Installed B : <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 WILL CALL FOR A GROUT INSPECTIONS <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE <br /> ARA PI6 T' PLAN 0 RE RSE SIDE <br /> FOR)APARTMENT USE ONLY <br /> s PHASE I <br /> APPLICATION ACCEPTED BY DATF� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS I/F AL INSPECTIO / <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> -71 <br /> F <br /> 3/76 214 <br /> t E H 1426 Rev. 1-74 <br />