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SAN JOAgUIN LOCAL HEALTH DISTRICT <br /> Hazelton tockton <br /> ,OFFICE USE: 1601 E. Ave. ,. , Calif. <br /> Telephone: (209) 46676781 <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 ,mede'in. compliance with San Joaquin <br /> Caurity Ordinance No. l$62 and the Rules. ss Joaquin Local. Health District. <br /> and Regulations of the San � <br /> JOB ADDRESS/LOCATION X1 3117 Nle. View - Mile East of CENSUS .TRACT ` <br /> ,j - sa <br /> 5-44.3-2570.: <br /> Owner's Name" Rash Dester ' Phone 1 <br /> 3 961 Stanford Way r _ City ' ' <br /> Livermore,, Cal <br /> Address <br /> illing Co. ., Inc <br /> 2�. � phone . 522-1031 <br /> Contractor's Name ' Hennings BrosDrLicense # <br /> . <br /> Rest um e -RCL- lvlotTesto, 95350 <br /> TYPE OF WORK (Check). NEW WELL DEEPEN '/r RECONDITION " T DESTRUCTION I�T <br /> PUMP INSTALLATION "/ PUMP REPAIR /� PUMP REPLACEMENT I—T <br /> Other,L%// <br /> 1 - <br /> DISTANCE TO NEAREST: SEPTIC STANK 12e? SEWER LINES. PIT PRIVY <br /> J'T. tri T6-a7/ SEWAGE 'DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL'. PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �rr <br /> E industrial Cable Tool - Dia. of°Well Excavation <br /> n <br /> gg Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> -501 <br /> Irrigation - Gravel Pack. Depth of Grout Seal <br /> e of Grout " Bentonite <br /> Cathodic Protections Type.yp `1 <br /> Other In€ormation' a <br /> Other ower <br /> Disposal --�- r� e�T <br /> � Geophysical . - - .._ . Surface Seal Installed H <br /> a PUMP INSTALLATION: Contractor H.P. <br /> f Type of Pump <br /> PUMP REPLACEMENT: • L/ ,State Work Donee <br /> PUMP :REPAIR:_ --/ State Work- <br /> DES:TRUCTION 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 L FOR:A,GROUT INSPECTION <br /> PRIOR TO GROUTING AND A'FINAL INSPECTION. eCt <br /> SIGNED Hennin s Bros,. -Drilling U0. 2 Inc. TITLE <br /> B U l <br /> i (DRAW PLOT. PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I .f DATE ' 7-= _ v <br /> A LICATION' ACCEPTED BY . <br /> ADDITIONAL COMMENTS: PHASE III' FiNAL INSPECTION <br /> PHASE II GROUT- INSPECTION; INSPECTION BY DATE <br /> INSPECTION BY �' , " DATE S" � <br /> a f c 1h 75. 2M <br />