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QO SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �Or.,OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELT, CONSTRUCTION OR PUMP PERMIT Permit No. <br /> F -- THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued Cf <br /> fl (Complete In Triplicate) <br /> for a permit to construe <br /> Application is he iiadeto the San Joaquin Local Health District <br /> and/or install the work herein described. , This application is made in compliance with San Joaquir <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 'IOQ I CENSUS TRACT <br /> Owner's Name _ Phone ec;�;7- Z52— <br /> Address <br /> GZ� <br /> City ' <br /> HENNINGS SRO& DRILLING CO., INC. <br /> Contractor's Name I License # P h o n e �-� <br /> BLE ROAD <br /> TYPE OF WORK (Check): NEW WELL%I DEEPEN /-7 RECONDITION_/ / DESTRUCTION /_7 <br /> PUMP INSTALLATION / / PUMP REPAIR /�/ PUMP REPLACEMENT /? <br /> Other <br /> t ;l <br /> DISTANCE TO NEAREST: . SEPTIC TANK JOG ' SEWER LINES PIT PRIVY C <br /> r SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS C <br /> Industrial Cable Tool Dia. of Well Excavation <br /> c�---Domestic/private 1 Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> Irrigation ravel Pack Depth of Grout Seal <br /> Other T j Rotary Type of Grout <br /> I Other Other Information <br /> PU`iT INSTALLATION: Con'tracto.r <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: �/ State Work Done <br /> State Work Done <br /> PUMP ,`tEPAIR: / / " <br /> I DFRTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 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 try w6ik on a new well, I mill furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPORT of the well and notify theta before putting the well in use. The above <br /> .information is true to the best of ,my knowledge and belief. <br /> { 4 Zz� <br /> SIGNED TI <br /> (D PLOT PLAN ON REVERSE ODE <br /> # -FOR DEPARTMENT USE ONLY <br /> PEASE I ' <br /> DATE <br /> APPLICATION ACCEPTED "BY <br /> ADDITIONAL CO}ZMNTS: I . <br /> PHASE II GROUT INSPECTION PHASE III .FINAL INSPECTION <br /> INSPECTION BY 3 DATE _7 INSPECTION BY DATE .S'=«f- 7•S/ <br /> CALL FORA. GROUT INSPECTION PRIOR TO.-GROUTING AND FINAL INSPECTION. <br /> 10 � ,,.1)� 5/731M <br />