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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 0_i,;u'rFICE USE: 1601 E. Hazelton: Ave. , Stockton, Calif. j <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 Disttict for a permit to construct 3 <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 Sana Joaquin Local Health District. � <br /> JOB ADDRESS/LOCATION Well # 1 San Jose & Middle Rd. CENSUS TRACT S <br /> Owner's Name Don Lose Phone 83 5-0966 <br /> Address P. 0. Box 326 citTracy, Cal. <br /> 1 C_5�1 <br /> Contractor's Name Hennings' Bros. Drilling Co. , Inc. License #290813 Phone 522-56+3 J <br /> TYPE OF WORK (Check): NEW WELL -/77 DEEPEN /7 RECONDITION /7 DESTRUCTION % <br /> PUMP INSTALLATION /-7PUMP REPAIR /7 PUMP REPLACEMENT /7 <br /> Other /_7 <br /> DISTANCE TO NEAREST: SEPTIC TANK /oz/ SEWER LINES OV e PIT PRIVY <br /> 10�� ,• SEWAGE DISPOSAL 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 <br /> 7. Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal 50a <br /> Cathodic Protection }-$ Rotary Type of Grout Renton-i to <br /> Disposal i Other Other Information S7�h_by_own Pr <br /> Geophysical +• Surface Seal Installed By: Hennings Bros <br /> PUMP INSTALLATION: Contractor Drilling Co. , Inc. _J <br /> •� <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: /_7 State Work Done <br /> PUMP :REPAIR: , LYZ <br /> pESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with! all laws and regulations of the Sari 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 an 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..weli in-use.. The above <br /> I` information is true to the•be`st.of my knowledge and belief. .I WILL CALL FOR"A GROUT INSPECTION I <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. , <br /> SIGNED TITLE LJc. <br /> D_ LOT FiM ON REVERSE SIDE <br /> R DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ DAME <br /> ADDITIONAL COMMENTS: <br /> I GROUT INSPECTION P IIF INSPECTION <br /> INSPECTION BY , _ DATE - S-7 INSPECTYn BY DATE ZZ <br /> ' Af ; <br /> E R"-1426,%. Rev. 1-74 1-74 2M <br />