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SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> FOE;OFFICE USE: 1601 E. Hazelton'Ave.; Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP, PERMIT Permit No. �_ -3SS4J. <br /> THIS PERMIT' EXPIRES 1 YEAR FROM DATE ISSUED Date Issued g__g-26 <br /> (Complete In Triplicate) . <br /> Application is hereby made to the San Joaquin Local Health '.District for a permit toconstruct . <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 ' <br /> CENSUS TRACT , <br /> Owner's Nameside Phone <br /> Address 8723 E. Melton Rd, City Mantaea <br /> Contractor's Name Hennings-Bros. Drillii CO. Inca License # '290813� Phone 522-1031 <br /> W. Eumble Ed. <br /> TYPE OF WORK (Check): NEW WELL -/%? DEEPEN '/? RECONDITION /-7 DESTRUCTION /7 <br /> PUMP INSTALLATION/ j PUMP REPAIR -/_7 PUMP REPLACEMENT <br /> Other %/ -- <br /> ,DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER 3 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL Mama <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing n r- <br /> Domestic/public _ Driven Gauge of Casing r,AW <br /> X ;Irrigation .Gravel Pack Depth of Grout Seal . <br /> Cathodic Protection " �X Rotary Type of Grout ; <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed_Bj <br /> PUMP INSTALLATION; Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Dane ! <br /> i <br /> PUMP-'REPAIR: - ---- _ - r <br /> . I__/ ,State Work Done . . 1 <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. INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED HENNINGS BROS . DRILLING CO. INC. BY-L- TITLE SEC-. <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> PHASE 2 FOR DEPARTMENT USE ONLY <br /> AF ILPCATION' ACCEPTED BY ��� DATE , �! 3 -7 i <br /> ADDITIONAL COMMENTS: <br /> PHAS I G OUT INSPECTION PHASE I F INSPECTI N <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> ' .. � <br /> E H 1426 bo., 1-71 -. �..w .u. <br />