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/ SAN JOAQUINi-�-LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: v 1.601 E. Hazelton Ave. , Stockton, Calif. <br /> x Telephone,: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE.,ISSUED Date Issued 3_2k Jd <br /> (Complete In Triplicate) <br /> Application is hereby made to: the San Joaquin Local Health District for a <br /> and/or instal]. the work herein described. . permit to construct <br /> This application is made tn. compliance .with San Joaquin. <br /> County Ordinance .No: 1862 an& the Rules: and Regulations of the Ban Jaaquin .Local; Health .Distriet. <br /> JOB ADDRESSAOCATION 6103 Northland Ave. North Sider�ao <br /> -° Ulit� CENSUS TRACT '. <br /> all Owner''s Name George"Alexander 823-161.9 <br /> Address 6103 Northland4 Pho <br /> Ave. .ne Manteca <br /> Mant . <br /> ,. . . City - <br /> f <br /> Contractor's Name HENNINGS I BROS. DRILLING CO.. INC. <br /> License #290813 Phone 522-1031 <br /> 00 West Rumble Rd, Modes o,. Tal. 95350 <br /> TYPE OF WORK (Check): NEW WELL ; <br /> I� DEEPEN J7 R' ECONDITION '/-7 DESTRUCTION f7., } <br /> PUMP INSTALLATION/ / PUMP REPAIR.-L-7—Pump REPLACEMENT /f <br /> Other / <br /> DISTANCE TO NEAREST: SEPTIC TANK b 5 SEWER LINES PIT PRIVY , <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER � # <br /> PROPERTY LINE PRIVATE DOMESTIC WELL" PUBLIC DOMESTIC WELL 1 <br /> INTENDED USE TYPE 0F WELL CONSTRUCTION SPECIFICATIONS <br />-. .. Industrial .1 - Cable Tool Dia. of Well Excavation <br /> Domestic/private i�"' Drilled Dia. of Well Casing <br /> �T 12�r <br /> Domestic/public <br /> 8 <br /> Driven - LLT Gauge-of-Casing rt= _._.. -12—Ga.. <br /> Irrigation d Gravel Pack Depth of Grout Seal 0f <br /> Cathodic Protection X Rotary Type of Grout Bentonite <br /> Disposal Other Other Information Driller <br /> Geophysical .: Surface Seal Installed 'B : <br /> PUMP INSTALLATION.. Contractor <br /> Type. of Pump H.P. <br /> PUMP REPLACEMENT. , / State Work Done <br /> PUMPIREPAIR: <br /> / / :State Work Done <br /> i <br /> DESTRUCTION OF. WELL: Well. Diameter <br /> Describe Material and Procedure Approximate Depth <br /> Y,d <br /> r. hereby .agree to comply with all, laws and regulationsof 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 /> 4ELL DRILLERS REPORT of the well a9d notify them before putting.. the..well.:in.use.... The above <br /> Lnformation is true to-the,best.-of..my. knowledge and belief. I WILLL �FOR A 'GROUT INSPECTION <br /> 2IOR TO GROUTING AND A FINAL INSPECTION.INC B <br /> iIGNED HENNINGS BR .., . TITLE SEC T t -BKPR <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br />,SEP I FOR DEPARTMENT USE ONLY <br />►PPLICATION ACCEPTED BY DATE <br /> ZDITIONAL COMMENTS. <br /> PBAS II ROUT INSPECTION <br /> INSPECTION BY PRASE II FIN INSPECTION <br /> DATE <br /> -. _ INSPECTION BY DATE <br /> E H_.1426Rev. ,1-74 <br /> _. �_ <br />