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13q�to� I Ova1+q ht, -W-- 51001--- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR•r.OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <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 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/LOCATI 0. SUS TRACT <br /> Owner's Name Phone <br /> Address e— 4 City <br /> Contractor's Name HENNINGS BROS. DRILLING INC. 290813 522-1031 <br /> CO.? License � Phone , <br /> 2500 W. RUM RD. IMMIST07 CAL. <br /> TYPE OF WORK (Check): NEW WELL DEEPEN/7 RECONDITION /? DESTRUCTION /7 <br /> PUMP INSTAL TION / / PUMP REPAIR /-7—pump REPLACEMENT %f <br /> Other /-7 — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL' PUBLIC DOMESTIC WELL \ i <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation -Q <br /> Domestic/private L..JDrilled Dia. of Well Casing 1.1-4 <br /> Domestic/public Driven Gauge of Casing i <br /> Irrigation I Gravel Pack Depth of Grout Seal 14 <br /> Cathodic Protection Z-.-Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed By: T <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> i <br /> PUMP REPLACEMENT: /_/ State Work Done <br /> PUMP :REPAIR: /7 State Work Done <br /> ES•TRUCTION OF WELL: Well Diameter Approximate. Depth <br /> Describe Material and Procedure i <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 , TITLE <br /> DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Q I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: ; <br /> PRA4EX,17610 INSPECTION PHASE <br /> IXTJFINAL INSPECTION <br /> INSPECTION BY % DATE INSPECTION BY DATE <br /> E H 1426 Rev. 1.74 1-74 2M <br />