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AC O `'" ' � �// 7.7 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF.:OFFI USE: 1.601 E. Hazelton Ave. ,..Stockton, Calif. <br /> — Telephone: (.209) 466-6782 14/ <br /> [ APPLICATION FOR" WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> ( L 7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED Date Issued . <br /> (Complete In Triplicate) <br /> Application is hereby madejto the San Joaquin Local Health District for a permit to �construct <br /> k and/or install. the work heiein described. ' This application is made i.n. compliance with San Joaqui>li <br /> County Ordi.nante .No. 1862 and the Rules and Regulations o£ t San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION � CENSUS TRACT <br /> Owner's Name BQB OLMO ' - — <br /> Phone- 599-2291 <br /> Address 2 a MILGEO city RIPON CAL <br /> Contractor's Name HENNINGS BROS. DRILLING CO. INC. License 7L�,6322 Phone 522-56432 <br /> 2 04 W.: Rumble Rd. Modes o Ca . 95350 _ ___-. - - <br /> TYPE OF WORK (Ch ck): NEW WELL'/ DEEPEN / / RECONDITION {_{ DESTRUCTION <br /> PUMP INSTALLATION / { PUMP REPAIR / / PUMP REPLACEMENT {-7 <br /> Other ./ / <br /> I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> XSEWA E'DISPOSAL .FIELD CESSPOOL{SEEPAGE PIT OTHER <br /> { <br /> } INTENDED. USE 'HYPE OF WELL CONSTRUCTION SPECIFICATIONS � <br /> Industrial j :' =LableTooI Dia. of WeIr Excavation rr <br /> Domestic/p ivate { + Drilled �' Dia: o Well Casing rr rr <br /> Domestic/public t Driven' Gauge of�Casing 12 R <br /> Irrigation] �i: i.I °Gravel Pack Depth of Grout Seal = <br /> j Other rte_ Rotary. Type of Grout Rantnni tp -- <br /> 'i Other 0"thet,iInformation <br /> l PUMP INSTALLATION: Contractor . <br /> I Type sof Pump # _ H.P. <br /> PUMP REPLACEMENT: (7/ State Work Done; <br /> a PUMP `tFaPAIR + - J�{ { State-Work= Done <br /> Approximate Depth <br /> t <br /> DF RUCTION OF WELL: Well Diameter PP P <br /> L - zDescribe 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 ofICal.ifornia pertaining to or regulating well''construction. Within FIFTEEN DAYS <br /> after completion'- of my wd.rk, on, a new well, I will furnish the San Joaquin Local Health District <br /> CELL 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. <br /> SIGNED i TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE} ! <br /> . FOR DEPARTMENT USE ONLY <br /> PHASE 'l <br /> APPLICATION ACCEPTED .BY fi <br /> DATE <br /> ADDITIONAL COMMENTS: <br /> P G T N ON PHA§E III/FINAL INSPE <br /> INSPECTION BY DATE - - INSPECTION BY DAT <br /> CALL FOR.-A GROUT-1-NSPECTION PRIOR-TO- GROUTING•AND-FINAL 3NSPECTION. <br /> D u 1479 - .5/731M <br />