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SAN JOAQUIN LOCAL_HEALT%DISTRICT � <br /> . FOSOFFICUSE; 1601 E. Hazelton Ave. , Stockton; Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. ,7__ l fD[J <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby• made to the Satz Joaquin Local Hea3:th District for a permit to construct <br /> and/or install,.tle-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 /> T% <br /> JOB ADDRESS/LOCATION Sout Wickland Rd. ��. CENSUS TRACT <br /> X Owner°s Name 1,eu) Phone <br />�( <br /> XCity <br /> Address <br /> IV <br /> . � y . <br /> Contractor's Name Hennings Bros . D yflling Co. , InC . License # 290813 Phone 522-1031 <br /> 0 W. Rumble 17. MocLes to, Cal 11 9 53 50 ' <br />-_ TYI'E-XF,,W0RK_(-Check-) NLW--WELL /_7i-'.DLEP-EN.-/ -:��CANDITION-h-/_ --.7i <br /> A PUMP INSTALLATION / / PUMP REPAIR /� PUMP REPLACEMENT -T - <br /> Other El <br /> DISTANCE TON T: SEPTIC TANK, SEWER LINES PIT PRIVY <br /> SEWAGE DISPOS FIELD ., CESSPOOL/SEEPAGE PIT OTHER p' <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL ' PUBLIC DOMESTIC WELL -11` <br /> rr INTENDED';USE'. �, , : .t TYPE OF WELL CONSTRUCTION SPECIFICATIONS � <br /> Industrial Cable Tool Dia. of Well Excfvation 11 _0 <br /> �, Domestic/private— Dritled —Dia.-of-Well Casing. w <br /> Domestic/public Driven' 0 <br /> Gauge of Casing ` a <br /> . Irrigation Gravel Pack Depth of Grout Seal <br /> E `Cathodic Protection X ' Rotary Type of Grout Rentoni te__ -- <br /> Disposal F Other Other Information Slab b owner-- <br /> . Geophysical Surface Seal Installed By: <br /> 1 � <br /> PUMP:"-INSTALLATION: Contractor <br /> Type of Pump MeH.P. <br /> _. <br /> PUMP REPLACEMENT: State Worts Done` <br /> PUMP :REPAIR: /*7 State Work Done �f7-7� <br /> PES-TRUCTION OF WELL: Well Diameter I Approximate Depth <br /> Describe Material and Procedure <br /> .M'NfvF <br /> Z 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 they,-San J.oaquin.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 MUTING AND A F ALSPECT ION. <br /> 4 SIGNED. TITLE <br /> ON REYF.$,SE S IDE <br /> FO DE MENT USE ONLY . <br /> PHASE I <br /> APPLICATION ACCEPTED' 2 DATE ` � <br /> r ADDITIONAL CO / <br /> IOAPUT INSPECTION <br /> INP, BY. '` DATE INSPECTt ON B DATE <br /> Yr <br /> Aw <br /> E 10.1426- `1 <br /> Rev. 1-74 _,. '" -74 <br />